Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Sandra Daniel

Lake Worth,FL

Summary

Highly motivated experienced registered nurse with a passion for the medical profession. Ability to function well in stressful situations and to prioritize and delegate work. Strong interpersonal and communication skills. Knowledge of computer software Windows, Microsoft word, Excel. Proficient in entering and retrieving data from electronic records. Comply with CMS regulations. Proficient in reviewing health records to identify proper diagnosis codes for billing. Proficient in using medical terminology and classifying diagnostic procedures and medications

Overview

16
16
years of professional experience
1
1
Certification

Work History

Authorization Nurse/Utilization Review

Sunshine Health Plan
02.2019 - Current
  • Approved services or forwarded request to Medical Director with recommendations for other determinations.
  • Conducted thorough reviews of medical records, identifying necessary documentation to support prior authorization requests.
  • Collaborated with various staff within provider networks and Case Management team electronically or telephonically to coordinate member care.
  • Assisted in maintaining compliance with changing regulations and policies by staying up-to-date on industry trends and best practices.
  • Verified member insurance eligibility, benefits, and demographics.
  • Processed requests, determined correct ICD-10 and CPT codes, and approved authorization for HH, DME.
  • Collaborated with healthcare providers to ensure accurate submission of required documentation for timely authorizations.

Authorization Nurse/UR

UnitedHealthcare
02.2018 - 02.2019
  • Performed clinical coverage review using state and federal mandates.
  • Verified member insurance eligibility and benefits.
  • Determined appropriateness and approved authorization request based on Milliman Guidelines or United Health UM Policy criteria.
  • Reviewed and determined the correctness of diagnosis and procedure codes, POS, and specialty services request or provider contract.
  • Worked independently and collaborating with Medical Directors and non-clinical partners.
  • Adapted to a highly changing environment and a heavy case load.
  • Functioned as a member of a self-directed team to meet specific individual and team performance metrics.
  • Acted as a resource for others with less experience.

Registered Nurse/ Utilization Review/Case Manager

University Hospital & Medical Center
05.2015 - 11.2018
  • Coordinated referrals and completed the screening and assessment on all clients assigned.
  • Ensured that all appropriate referrals for identified services on the service plans are made and coordinated with services providers via contracted network providers or community resources.
  • Maintained complete and accurate computerized management notes on each case.
  • Attended daily interdisciplinary meetings to coordinate discharge and reduce LOS.
  • Utilized InterQual Level of Care Criteria to assess the safest and most efficient care level on severity of illness.
  • Identified the health needs of the patient and the expectations of the family.

Registered Nurse

Cleveland Clinic of Florida
04.2008 - 11.2018
  • Responsible for the complete nursing process for the adult patients.
  • Managed and directed nursing care activities during the patient’s hospital stay.
  • Identified short- and long-term goals based on patients’ needs.
  • Provided and documented nursing interventions based on assessed patients’ needs and plan of care.
  • Collaborated with appropriate health care team members for coordination of daily plan of care for assigned patients.
  • Involved the family when providing care and in decision-making as appropriate.
  • Documented the effectiveness of nursing care and modified plan of care as patient progresses toward expected outcomes.
  • Maintained a high degree of accuracy to achieve optimal patient acuity monitoring.

Education

Medical Coding -

AAPC
Salt Lake City, UT
07.2023

Certification - Billing And Coding

Penn Foster Career School
Scranton, PA
02.2023

Bachelor of Science - Nursing

University of West Florida
Pensacola, FL
12.2018

Associate of Science - Nursing

Broward Community College
Davie, FL
12.2007

Associate of Arts -

Nassau Community College
Garden City, NY
08.2000

Skills

  • Patient Health Information Access
  • Disease Processes
  • Company Guidelines
  • Microsoft Office
  • Accurate Documentation
  • EMR Systems
  • Medical Terminology
  • Procedural Codes
  • Diagnostic Codes
  • ICD-10 Requirements
  • Reviewing Patient Information

Certification

• Current Florida/Multi-state Registered Nurse license

• Current New York State Registered Nurse License

• Current BLS certification

• Certified Case Manager

• Certified Professional Coder

Timeline

Authorization Nurse/Utilization Review

Sunshine Health Plan
02.2019 - Current

Authorization Nurse/UR

UnitedHealthcare
02.2018 - 02.2019

Registered Nurse/ Utilization Review/Case Manager

University Hospital & Medical Center
05.2015 - 11.2018

Registered Nurse

Cleveland Clinic of Florida
04.2008 - 11.2018

Medical Coding -

AAPC

Certification - Billing And Coding

Penn Foster Career School

Bachelor of Science - Nursing

University of West Florida

Associate of Science - Nursing

Broward Community College

Associate of Arts -

Nassau Community College

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Sandra Daniel