Sandra Wheeler
Cameron
Summary
To utilize my compact nursing license and experience as an Appeals and Grievances Registered Nurse. The Goal is to be thoughtful and proactive in making an impact in a team environment. Actively searching for opportunities to make an efficient and positive impact in managed care.
Experienced healthcare professional prepared for this role with strong emphasis on patient care and clinical skills. Proven ability to work collaboratively within multidisciplinary teams, adapting to changing situations with ease. Excels in communication, empathy, and problem-solving to achieve optimal patient outcomes. Reliable and results-driven, with focus on delivering high-quality care and maintaining positive, supportive environment.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Onsite Nurse Assessor
The Helper Bees
Austin, TX
02.2022 - Current
- Executed comprehensive cognitive and functional assessments for long-term insurance clients, ensuring accuracy and efficiency.
- Coordinated scheduling assessments with clients and families. Observed and reported on the status of the insured in daily living activities and instrumental activities of daily living.
- Submitted assessments in GoCanvas within 24 hours of completion. Addressed clarifications from review team within 48 hours.
Senior Appeals and Grievances Nurse
Evolent Health
Arlington, VA
12.2020 - Current
- Conducted thorough analysis, review, and evaluation of appeals to ensure compliance with state and federal regulations for Medicaid health plans.
- Supported post-service and expedited appeals by leading a team of five RNs. Supervised daily operations to ensure efficient workflow and timely responses. Assisted team members in resolving complex cases and improving service delivery.
- Conducted comprehensive research and analysis of appeals, ensuring alignment with medical policies, InterQual criteria, and NCQA guidelines.
- Facilitated escalation of cases to medical director for secondary review of requested services. Provided clear situational descriptions to support medical director in making informed decisions.
- Conducted monthly audits of nursing practices for post-service appeals. Identified and addressed quality of care issues. Achieved key performance indicators and metrics at 100%.
- Championed safe space initiatives as an ambassador, fostering inclusivity and support.
- Collaborated with various business lines, including Medicare, Medicaid, and commercial/HMO, to support appeal resolution processes. Assisted in resolving post-service, pre-service, and emergency room appeals efficiently.
- Assisted in drafting comprehensive appeal letters for providers and members regarding overturned, partially overturned, or upheld decisions. Supported the appeal process for both level 1 and level 2 cases.
- Directed patient care management to ensure compliance with clinical guidelines and protocols.
- Designed and executed personalized care plans addressing unique patient needs and preferences.
Case Management Registered Nurse
Evolent Health
Arlington, VA
02.2018 - 12.2020
- Managed telephonic case management for a caseload exceeding 60 adult Medicaid members, ensuring effective communication and support.
- Executed comprehensive telephonic assessments addressing medical, behavioral, pharmaceutical, and social needs of members.
- Delivered educational sessions on health and wellness, focusing on chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, and heart failure.
- Facilitated self-management education for chronic conditions using motivational techniques to enhance patient autonomy.
- Facilitated collaboration among utilization management, physicians, and community providers to streamline referrals for case management services.
- Facilitated collaboration among interdisciplinary teams to enhance care delivery standards.
Utilization Management Registered Nurse
Evolent Health
Arlington, VA
09.2015 - 02.2018
- Assessed health plan member eligibility for inpatient, outpatient, transplant services, hospitalizations, and surgeries.
- Assessed medical necessity for requested services and authorized inpatient hospitalizations by applying clinical information to InterQual criteria and health plan policies.
- Processed prior authorization requests for inpatient services including elective surgeries, skilled nursing admissions, rehabilitation, and chemical dependency treatment facilities. Assisted in meeting timeliness requirements set by Centers for Medicare & Medicaid Services (CMS).
- Facilitated referrals to case management for health plan members requiring education on chronic health conditions.
- Facilitated escalation of cases to medical director for secondary review of requested services. Provided clear situational descriptions to support medical director in making informed decisions.
- Assisted team in executing plan-specific training sessions and addressing utilization management issues. Achieved consistent performance in utilization review audits with 100% compliance.
- Developed and executed patient care plans to enhance treatment adherence and improve patient outcomes.
- Facilitated collaboration among interdisciplinary teams to enhance communication and improve patient care processes.
Home Health Case Manager
Buckeye Home Healthcare
Centerville, OH
02.2013 - 09.2015
Home Health Case Manager
Kettering Network Homecare
Kettering, Ohio
06.2010 - 02.2013
Integrative Care Manager/Psychiatric Utilization Review Nurse
Miami Valley Hospital
Dayton, Ohio
01.2001 - 06.2010
Education
Bachelor of Science in Nursing -
Wright State University
Fairborn, Ohio01-1995
Skills
- Effective case management
- Skilled in accurate clinical documentation
- Data-driven problem solving
- Clear communication
- Strong organizational skills
- Prioritize projects
- Cross-functional teamwork
- Process improvement
- Writing investigation summaries
- Health education delivery
- Healthcare advocacy
- Supervisory skills
- Home health
- Medical surgical/Geriatric nursing
- Psychiatric nursing
- Managed healthcare services
- HIPPA
- InterQual Criteria
- Utilization review
- Denial management
- Training
- Chronic condition management
- Quality assurance/chart audit
Certification
- State of North Carolina Compact License-License# RN9548760
- Basic Life Support
ADDITIONAL INFORMATION
- COMPUTER & TECHNICAL SKILLS: Proficient in: Microsoft Office
- EPIC
- Citrix/Care Manager
- Identifi, InterQual Criteria
- Microsoft Word
- Microsoft Excel
- Homecare electronic medical record: Homecare HomeBase, WellSky, Axxess, Alora, Cerner, Allscripts.
Timeline
Onsite Nurse Assessor
The Helper Bees
02.2022 - Current
Senior Appeals and Grievances Nurse
Evolent Health
12.2020 - Current
Case Management Registered Nurse
Evolent Health
02.2018 - 12.2020
Utilization Management Registered Nurse
Evolent Health
09.2015 - 02.2018
Home Health Case Manager
Buckeye Home Healthcare
02.2013 - 09.2015
Home Health Case Manager
Kettering Network Homecare
06.2010 - 02.2013
Integrative Care Manager/Psychiatric Utilization Review Nurse
Miami Valley Hospital
01.2001 - 06.2010
Bachelor of Science in Nursing -
Wright State University