Shelly Petell
RN UM/CM
Colorado Springs,CO
Summary
I am an RN, certified case manager and a utilization manager senior. I have previous Med/Surg, Oncology and Ostomy/Diabetic wound care hospital/clinic experience. I have multiple computer programs experience as I have worked virtually for almost seventeen years. I have a steadfast commitment to quality care. I started working with Wellpoint/Anthem/Elevance Health in February of 2007 and have been in several roles with this company. I started as a Utilization Management II for HMO reviews and quickly promoted to a Senior nurse. I performed case management, ultilization management for Medicaid division, including precertifications and discharge planning. I have done precertification for commercial business and have excelled in all aspects of my work with multiple appreciation awards. My last role with Anthem was the author of the high length of stay report for actuary and was filled with research and ended up in cost savings for the company. I am considered a valuable asset to any team.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Medical Management Senior
Anthem/Elevance Health
Camarillo, CA
03.2021 - 10.2023
- Author of high dollar/ high length of stay reports, which is used by actuarial staff and submitted to executive leadership. The duties of this role include data retrieval from internal systems, data analysis to ensure the right members are listed on the report, as well as authoring both detailed case summaries and high-level executive summaries of each case.
- Also included in the duties of this role is research and reporting on claims and total billed charges, using internal systems and outreach to external providers for this information.
- This role also includes identifying discrepancies in data, potential quality issues or sentinel events that occurred during patient care and ensuring they are reported/ investigated and/or resolved.
- Conducted out of state concurrent reviews using all of the internal data systems and EMR's from facilities. Collaborated with internal physicians for cases unable to be approved by MCG guidelines and internal processes. Sent for review to physicians when needed.
Medical Management Nurse Senior
Anthem Blue Cross
Camarillo, CA
03.2016 - 03.2021
- Conduct precertification, continued stay review, care coordination and discharge planning for appropriateness of treatment setting, post service reviews that ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
- Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. Assists with development of utilization/care management team processes and serve as resource to lower-leveled nurses and may participate in or lead intradepartmental teams, projects and initiatives.
UM Medical Management Senior HMO and Medicaid
WellPoint, Anthem Blue Cross
Camarillo, CA
02.2007 - 03.2016
- Reviewed and analyzed concurrent clinical provided by medical groups or hospitals for inpatient hospital stays to determine medical necessity according to established guidelines.
- Reviewed, analyzed and rendered determinations on requests from the hospitals for inpatient stays within established timeframes.
- Concurrent/Retro, Medicaid as well as PPO precertification CM/UM work in State Sponsored Business working with hospitals for continued stay for low income or homeless communities.
- Responsible for discharge planning, letter of agreements, acute rehab reviews and more in the Medicaid business unit and currently in the PPO inpatient precertification department for the Commercial Health Care side of business.
- Trained incoming nurses on procedures, guidelines and every line of business used for rendering decisions for inpatient concurrent reviews, precertifications, retro reviews, in and out of network reviews and discharge planning.
Education
Bachelor of Science - Metaphysics
Sedona University
Online09-2020
Certified Health Coach - Foods, Nutrition, And Wellness Studies
Institute of Integrative Nutrition
09-2012
Associate of Science - Nursing
Moorpark College
Moorpark, CA12-2005
Associate of Arts - General Studies
Moorpark College
Moorpark, CA12-2003
Skills
- Broad medical terminology knowledge
- Committed to quality care
- Culturally sensitive
- Strong work ethic
- Trained in in- patient and out- patient care
- Ostomy and Diabetic wound care
- Virtual Learning Management
- Attention to Detail
- Decision-Making
- Resource Coordination
- Data Organization
- Coaching and Development
- Critical Thinking
- In-Depth Research
- Quality Assurance
Certification
California RN license 679330, active
Nevada RN license 75422, active
Colorado RN license 1656522, active
Certified Case Manager CCMC January 2013, active
Affiliations
- I am an avid reader and love learning new things.
- Reiki healer
References
References available upon request.
Timeline
Medical Management Senior
Anthem/Elevance Health
03.2021 - 10.2023
Medical Management Nurse Senior
Anthem Blue Cross
03.2016 - 03.2021
UM Medical Management Senior HMO and Medicaid
WellPoint, Anthem Blue Cross
02.2007 - 03.2016
Bachelor of Science - Metaphysics
Sedona University
Certified Health Coach - Foods, Nutrition, And Wellness Studies
Institute of Integrative Nutrition
Associate of Science - Nursing
Moorpark College
Associate of Arts - General Studies
Moorpark College
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