Rosa Landry
Las Vegas,NV
Summary
Motivated professional with attention to detail and the ability to effectively resolve issues. Poised and calm in high-pressure environments. Seeking a role as Appeals Manager at a new organization. Offering 6 years' experience in reviewing compliance standards and auditing charts. Knowledgeable Appeals Nurse skilled in medical data gathering, analysis, and authorization obtainment. Flexible and dedicated team player ready to contribute to success. Organized and motivated employee seeking entry-level opportunities to expand skills and support company growth.
Overview
16
16
years of professional experience
Work History
Clinical Review Nurse/ Complex Discharge Planner
Centene
Las Vegas, NV
03.2022 - Current
- Reviewed patient records for accuracy, completeness, timeliness, and appropriateness of care prior to authorization requests.
- Assessed clinical data from multiple sources including but not limited to medical records, lab results, radiology reports, medication administration records.
- Performed medical necessity reviews of inpatient and outpatient services to ensure compliance with relevant regulations and standards.
- Developed individualized discharge plans for patients based on their medical and psychosocial needs.
- Conducted assessments to assess patient's level of functioning and identify appropriate resources upon discharge.
- Collaborated with other healthcare professionals to ensure successful transition from hospital to home setting.
- Identified any potential barriers or risks that may impede successful outcomes post-discharge.
- Assisted in the coordination of services needed after hospitalization such as home health care, durable medical equipment, transportation.
- Participated in multidisciplinary team meetings when determining appropriate levels of care prior to discharge.
- Developed individualized discharge plans for hospitalized individuals according to their physical and mental health needs.
- Coordinated community resources such as housing, food banks, financial assistance programs. for discharged patients who need additional support after leaving the hospital.
- Planned and coordinated discharge from care facility to patient's home.
Review Coordinator/Case Management
Livanta
Annapolis Junction, MD
01.2015 - Current
- Complied with confidentiality regulations in handling customer information.
- Process and prepare medical records for physician review.
- Conduct case reviews and determinations calls to patients, providers and manage care plans.
- Juggled multiple projects and tasks to ensure high quality and timely delivery.
- Demonstrated self-reliance by meeting and exceeding workflow needs.
Registered Nurse- Chart Reviewer
HMS/Gainwell
Irving, TX
07.2018 - 03.2022
- Drafted denial correspondence for initial and subsequent appeals
- Proficiently processed claims through the use of InterQual, Milliman criteria, and Critical Review Judgement techniques.
- Conducted evaluations to confirm medical criteria for patient readmission
- Advanced work involving diagnostic related groups
- Complied with confidentiality regulations in handling customer information.
- Demonstrated self-reliance by meeting and exceeding workflow needs.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Evaluated cases using medical criteria and clinical judgment.
- Assessed medical necessity of patient admissions based on inpatient criteria guidelines
Registered Nurse Case Manager
Health and Care Professionals
Las Vegas, NV
08.2008 - 01.2018
- Collaborated with physicians on patient medications and medical needs.
- Perform intakes, patient care plans, overall patient health assessments and evaluations.
- Actively participated in family and patient planning processes.
- Administered medications and treatment plans in accordance with physician orders.
- Supervised and trained disciplines per agency policy.
- Review charts monthly for compliance.
- Assess and improve disease process prevention and education process
Education
Associate of Arts - Nursing
Kaplan College
Las Vegas, NV05.2013
Bachelor of Arts - Fine Arts
Hampton University
Hampton, VA05.2001
Skills
- Computer skills
- MS Office
- Analytical Problem Solving
- Time Management Expertise
- Healthcare Vocabulary
- Efficient Prior Authorization Processing
- Consistent Progress Reviews
- Utilization review
- Geriatric treatment knowledge
- Patient Discharge Management
- Diabetes management
- Thoughtful Listening Techniques
- Medical History Recording
- Information Classification
- Patient Medical Records Maintenance
- Strategic Planning
- Cost savings and reduction
- HIPAA Compliance
- Nursing process
- Evidence-Based Practice
- InterQual training
- Critical Thinking
- Teamwork and Collaboration
- Computer Skills
- Multitasking
- Team building
- New Hire Onboarding
Timeline
Clinical Review Nurse/ Complex Discharge Planner
Centene
03.2022 - Current
Registered Nurse- Chart Reviewer
HMS/Gainwell
07.2018 - 03.2022
Review Coordinator/Case Management
Livanta
01.2015 - Current
Registered Nurse Case Manager
Health and Care Professionals
08.2008 - 01.2018
Associate of Arts - Nursing
Kaplan College
Bachelor of Arts - Fine Arts
Hampton University
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