Summary
Overview
Work History
Education
Skills
Timeline
Generic

Rose Ruffin

collinsville,ms

Summary

Dynamic Quality Management Nurse Consultant at CVS Health Corporation with expertise in clinical documentation and utilization review. Proven ability to enhance service delivery through critical thinking and collaboration, ensuring compliance with regulatory standards. Successfully resolved complex cases, demonstrating strong decision-making skills and a commitment to evidence-based practice.

Overview

3
3
years of professional experience

Work History

Quality Management Nurse Consultant

CVS HEALTH CORPORATION
Collinsville, MS
04.2024 - Current
  • Conducted investigations into complaints or grievances filed against facilities, providers, and healthcare personnel.
  • Reviewed documentation, claims, and interpreted data from medical records or systems, and used clinical decision-making to apply appropriate criteria and policies in line with regulatory and accreditation requirements for member and provider claims.
  • Independently coordinate clinical resolution with clinicians and the Medical Director's support, as required.

Clinical Nurse Reviewer

Elevance
Collinsville, MS
03.2023 - 04.2024
  • Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
  • Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
  • Determined medical necessity and cost-effectiveness of services through utilization review processes.
  • Utilized evidence-based guidelines to support utilization review decisions and recommendations.
  • Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.

Case Manager

Change Healthcare
Collinsville, MS
09.2022 - 12.2022
  • Counseled clients on available resources within the community that could help meet their needs.
  • Assessed clients' needs, developed service plans and monitored progress towards goals.
  • Monitored client progress through regular follow-ups and case reviews.
  • Educated clients about mental health conditions, medications and self-care techniques.

Education

Associate of Science - Nursing

Meridian Community College
Meridian, MS
05-2002

Skills

  • Clinical documentation
  • Utilization review
  • Medical necessity
  • Collaboration skills
  • Critical thinking
  • Evidence-based practice
  • Data analysis
  • Decision making

Timeline

Quality Management Nurse Consultant

CVS HEALTH CORPORATION
04.2024 - Current

Clinical Nurse Reviewer

Elevance
03.2023 - 04.2024

Case Manager

Change Healthcare
09.2022 - 12.2022

Associate of Science - Nursing

Meridian Community College

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