Shelly Ross
Bowling Green,Ohio
Summary
Professionally trained Registered Nurse with experience ensuring high standards of care for a wide variety of patients with diverse needs. Have 21 years of experience providing nursing care to diverse populations while multi-tasking and managing a team under stressful situations, Utilization Review, and being a team leader. Have Precepted and trained many new employees over the years. 2019 Excellence in Nursing Nominee. Seeking to work with a Company that offers high standards of care for patients placing the patient needs first. Utilization management professional with strong expertise in clinical review, case management, and patient advocacy. Adept at collaborating with healthcare teams to ensure optimal resource utilization and quality patient care. Known for adaptability, reliability, and results-driven approach in dynamic healthcare environments. Skilled in clinical assessment, regulatory compliance, and effective communication.
Overview
22
22
years of professional experience
Work History
Utilization Management
Elevance Health/Anthem
09.2022 - Current
- Enhanced patient care by efficiently coordinating utilization management processes and reviewing medical records for case appropriateness.
- Supported compliance with industry regulations by maintaining up-to-date knowledge of utilization management guidelines and procedures.
- Ensured compliance with regulatory requirements through consistent adherence to established policies and procedures for utilization management nursing practice.
- Collaborate with case management and refer members for case management to ensure quality care.
- Review inpatient clinical to ensure cases meet inpatient approval and refer cases to medical director when criteria is not met.
- Process denial letters when inpatient criteria is not meet and fax denial letters to the facility.
- Performs accurate and complete verification of eligibility, benefits, and coverage and applies this information for Inpatient Reviews to determine the appropriate level of care.
- Maintains confidentiality and compliance adhering to Health Insurance portability and accountability Act (HIPPA) guidelines when reviewing medical documentation.
- Mets and exceeds accuracy and quality standards efficiently multitasking and triaging caseload.
Utilization Management Acute Care Coordinator
Paramount Health Care
04.2021 - Current
- Performs accurate and complete verification of eligibility, benefits, and coverage and applies this information for Inpatient Reviews to determine the appropriate level of care.
- Responsible for referring to complex clinical and medical procedure request to the medical director for review.
- Maintains confidentiality and compliance adhering to Health Insurance portability and accountability Act (HIPPA) guidelines when reviewing medical documentation.
- Mets and exceeds accuracy and quality standards efficiently multitasking and triaging caseload.
- Processes and reviews clinical documentation for the purpose of utilization review determinations and effectively communicates with facility, and other team members to ensure quality of care for the member.
- Works Independently processing Inpatient Authorization request by utilizing critical thinking skills, excellent communication skills, organizational skills, and time management.
- Request clinical information in a timely manner and provides Utilization review determinations in written or verbal format.
- Works remotely and has experience with True Care, Teams, Microsoft office, and InterQual.
- Assesses member for case management and makes referrals to provide the member with the best care possible.
- Performs concurrent reviews of clinical information to determine if member is receiving appropriateness and medical necessity of hospitalization and treatments using InterQual criteria.
- Experience with Medicaid and Medicare.
- Used denial template to process denial letters when criteria was not meet for inpatient stay.
Register Nurse
Wood County Hospital
05.2004 - 04.2021
- Started off at Wood County Hospital as a certified nursing student assisting with daily needs such as bathing, personal care, dressing changes and answering call lights while obtaining my associates degree of nursing. Then in 2004 I obtained my associates degree of nursing and worked on a medical/surgical/pediatric floor for 11.5 years at Wood County Hospital. In December of 2015 I accepted a positioned at Wood County Hospital in the Out-patient Infusion Center. While I worked on the medical/surgical/pediatric floor I gained experience as a team leader, IV starts, passing oral and IV medications, assessments, taking and carrying out doctors' orders. I also was a preceptor and trained many new employees. While working in the Infusion Center. I have learned to insert PICC lines, moderate sedation, assist with procedures throughout the hospital, IV starts with the ultrasound and give specialized medications. Throughout my 18 years of experience I have learned how to work well with others and manage time well, and have developed strong communication skills. I also have helped patients arrange care after they are discharged from the hospital or helped patients receive the care they need after visiting the Out Patient Infusion Center and utilize the resources that are available within the Community to ensure they are receiving the best care possible. I also worked at the Heart Failure Clinic and have strong assessment skills and handled incoming triage calls to help keep patients out of the hospital. I collaborate with providers to assess the needs of the patients to help provide the best care possible. I also have experience with electronic medical records. I also do chart reviews for the unit and complete chart audits for moderate sedation patients.
Clinical Instructor
Brown Mackie College
08.2016 - 01.2017
Education
Bachelor of Science -
Chamberlain College of Nursing
05.2016
Associate's Degree - Nursing
Owens Community College
Toledo, Ohio12.2004
High School Diploma - undefined
Lakota High School
Kanas, Ohio05.2000
Skills
- Effective utilization management
- Effective time management
- Effective verbal communication
2019 Excellence in Nursing Nomination
- Complete 3 of the 6 focused values clearly portraying why you feel this nurse excels in these areas. You must provide examples if you want your nomination to be considered!
- I would like to nominate: Name of Nurse Shelly Ross
- Department OPTIC for EXCELLENCE IN NURSING because:
- Clinical Care: Shelly is an excellent clinician. She has a thorough knowledge of the multiple procedures and vascular access placement necessary in the OPTIC department. She is consistent in her care of both inpatients and outpatients and also assists with Performance improvement data collection, in an effort to improve the overall performance of the department as a whole.
- Teamwork: Shelly is a team player in that she helps out wherever she is needed when she is working. She has never hesitated to give a helping hand on Med Surg or at the monitors. She has altered her schedule to meet the units needs. She often fills in for the secretaries or assists them when things are busy for them.
- Customer Service: Shelly has a smile that can light up a room and is, at the same time, filled with compassion. She is kind and soft spoken with patients and always seeks to find the easiest route for the patient. Recently, a patient required admission for IV antibiotics, despite a full schedule, it was very important to Shelly to not only accommodate the patient but make sure that he could come in as soon after a pain management appointment as possible.
- Leadership:
- Patient Advocacy: Shelly is compassionate and consistently acts as a patient advocate as above - always seeking to meet the patient's needs and preferences to the best of her ability.
- Patient and Family Education: Shelly is patient and takes as much time as is needed to assure that her patients are well educated regarding the process and their diagnosis. She sits with them and, to anyone watching her, appears as if she has nothing better to do and all the time in the world to make sure that they have a complete understanding. That kind of demeanor is important to a patient and their family member as it ensures that they are likely to feel comfortable asking any question that they may have. Shelly never seems hurried to get to another task or patient. The patient in front of her is always her priority.
- Signature (Required): Send the completed form to Nursing Education by April 19th 2019
- Upon receipt of nomination, nominee will be contacted and encouraged to attend the Nurses Week Kick off Celebration with their family on May 6th starting at 5pm at which time winners will be announced. You and your peers are also asked to join the celebration kick off.
Timeline
Utilization Management
Elevance Health/Anthem
09.2022 - Current
Utilization Management Acute Care Coordinator
Paramount Health Care
04.2021 - Current
Clinical Instructor
Brown Mackie College
08.2016 - 01.2017
Register Nurse
Wood County Hospital
05.2004 - 04.2021
Associate's Degree - Nursing
Owens Community College
High School Diploma - undefined
Lakota High School
Bachelor of Science -
Chamberlain College of Nursing