Rhonda Christian

-perform medical claim reviews one or more of the following: claims for medically complex services, services that require preauthorization/predertmination, requests for appeal or reconsideration

-make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets of clinical guidelines

-determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement

-monitor's processes and timeliness in accordance with contractor standards

-documents medical rationale to justify payment or denial of services and/or supplies

-educates providers regarding medical review determinations, coding procedures, etc in accordance with contractor guidelines

-participates in quality control activities in support of the corporate and team-based objectives

-worked on multidisciplinary team of registered nurses, social workers, pharmacists, and nutritionists to provide care coordination to Alabama Medicaid patients with chronic health conditions

-completed in-home comprehensive nursing assessments to determine medical and social needs for each patient and created individualized care plans based on patient centered goals

-ensured patient needs were met fairly and accordingly by collaborating with physicians, specialists, resource providers, etc to schedule appointments, obtain referrals, and obtain prescriptions

-provided patient education to assist patients with independency and self management of various disease processes, including but not limited to diabetes, hypertension, COPD, asthma, hepatitis C, mental health, autoimmune disorders, etc

-provided resources, education, and assistance with obtaining treatment for patients with psychiatric and substance abuse disorders

- formulated patient care plans and documented patient information via Symphony medical software

-reviewed patient medications, hospital visits, and medical claims to ensure medication safety, determine patient compliance and decrease hospital admissions

-consulted social workers to address social and housing needs of patients

-provided with community resources for food, clothing, DME, support groups, counseling etc

-completed consents and enured HIPAA compliance

-provided wide variety of wound care, including application of wound vacs, EZ-total contact casts (with MD), etc

-monitored, recorded and reported symptoms or changes in patients' conditions

-followed infection control procedures

-participated in Case Manager Role with surgeon by assisting with procedures and coordinating proper DME

- instructed patients and family members on proper discharge care

-referred patients to specialized health resources or community agencies furnishing assistance

-maintained accurate, detailed reports and records

-prepared rooms, sterile instruments, equipment, and supplies and ensured that stock of supplies was maintained

-ensured efficacy of treatments through monitoring of treatment regimens

-ensured HIPAA compliance

-provided care and education for patients with bipolar disorder, depression, schizoaffective disorder and those with generalized mood disorders, as well as other chronic medical conditions requiring medications

- interpreted and explained information such as eligibility requirements, application details, payment methods, and applicants legal rights

-initiated procedures to grant, modify, deny, or terminate assistance, or refer applicants to other agencies for assistance

-compiled, recorded and evaluated personal and financial data in order to verify completeness and accuracy, and to determine eligibility status

-interviewed benefit recipients at specified intervals to certify their eligibility for continuing benefits

-investigated claimants for the possibility of fraud or abuse

-provided family planning, immunization, and STD services

-performed physical assessments, obtained vital signs, ordered lab work, and obtained lab specimens via venipuncture

-provided case management to patients with complex medical conditions by consulting with area nursing homes, home health care agencies, hospices, DME suppliers and nutritional parenteral suppliers

-provided support, pain, and symptom relief to patients during the last stages if life as well as provided support to patients' families

-cared for patients with end-stage renal disease by performing hemodialysis, peritoneal dialysis, and administering blood/blood products

-managed respiratory ventilators and cardiac monitors as well as interpreted cardiac rhythms

-Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.

-Administered medications safely according to established guidelines while closely monitoring for side effects or adverse reactions requiring intervention.

-provided care for patients in the home setting including care of wounds, gastric tubes, foley catheters, supra-pubic catheters, venipuncture and IV therapy

-Provided emotional support for patients and families during difficult times, helping them navigate the healthcare system with compassion and understanding.

-Updated patient charts with data such as medications to keep records current and support accurate treatments.

-Participated in staff meetings and continuing education programs to stay current on best practices and maintain licensure requirements.

-performed head to toe physical assessments of patients with myocardial infarctions, congestive heart failure and cardiac dysrhythmia

-managed arterial lines and respiratory ventilator

-educated patients and families on medications and disease processes