Sherrie Torrell Pruitt
Lawrenceville,Georgia
Summary
Nursing professional with experience in acute, long term, urgent and primary care environments. Proficient user in Electronic Medical Records (EMR) software include the following: Meditech, Phoenix, Epic, Paragon, and Cerner). Proficient in computer software applications including Microsoft Word, Excel, and Outlook. Additional experience in Utilization applications such as MCSDT (Multi-Carrier Desktop) Application System, MAS (CMS Manual system), and McKesson InterQual Criteria system.
Overview
12
12
years of professional experience
Work History
Sub-Contractor
TMHP, Texas Medicaid and Healthcare Partnership
- Website: http://www.tmf.org Contract with TMHP (Texas Medicaid and Healthcare Partnership) http://www.tmhp.com
Skilled Nursing Facility/Rehabilitation
Cornerstone Gardens Health Care and Rehabilitation
- Website: http://www.cornerstonegardensllp.com Supervisor: Mrs
- Terri Freehill, RN (Director of Nurses) Phone :( 254) 771-5950, may contact
- Reason for leaving: spouse retired after 23 years in the United States Army, this is now my permanent state of residence, relocated from Fort Hood, Texas to Austin, Texas
- Supervised (1) LVN, (3-4) GNAs (Geriatric Nursing Assistants)
- Total unit capacity: up to 42 patients (Long-term/skilled unit and 36 patients (Rehabilitation Unit)
- Inventory count of pain medications for each patient, receive reports on patients, assigned work duties to staff, assess, and document plan of care of all patients
- Documentation of Fall Protocols, change of condition reports, Medicare, and risk assessments
- Protect operations by maintaining patient confidentiality.
Supervisor
Seton Medical Center Harker Heights, Central Texas Expressway
- Website: http://setonharkerheights.net/, Mrs
- Melinda McClendon, RN (Director of Med-Surgical/ ICU) Phone: (254) 680-6327, may contact
- Reason for leaving spouse retired after 23 years in the United States Army, this is now my permanent state of residence, relocated from Fort Hood, Texas to Austin, Texas
- Job Duties: Supervised (3) RNs (2-3) PCAs (Patient Care Technicians)
- Responsible for planning and delivery of direct and indirect patient care through the nursing process of assessment, planning, intervention, and evaluation
- Developing nursing care plan in coordination with patient, family, and interdisciplinary staff as necessary
- Patients to nurse ratio: 5:1
- Float between units including Medical-Surgical with telemetry cardiac monitoring, Emergency Department, and Intensive Care Units
- Functions as relief charge nurse as needed.
Supervisor
Adventist Health Care System
- Ms
- Faye Woodard, MSN RN (Nursing Night Supervisor) Phone: (254) 519-8182, may contact
- Reason for leaving: Unable to work two jobs, hours conflicting with current position
- Job Duties: Establish a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families
- Promotes patient's independence by establishing patient care goals; teaching patient and family in understanding condition, medications, and self-care skills; answering questions
- Patients to nurse ratio: 1:7
- Float between varieties of units including Medical-Surgical with telemetry cardiac monitoring, Ortho-Surgical, and Progressive Care Units
- Document assessments using Citrix electronic system., Mr
- Clarence Sampson (Manager) Phone: (410) 358-3410 or (410) 358-0432, may contact
- Reason for leaving: Spouse received military orders, relocated to Fort Hood, Texas
- Job Duties: Supervised (1) LVN, (3) GNAs (Geriatric Nursing Assistants)
- Total unit capacity: up to 48 patients
- (Long-Term Care Unit and SNF (Skilled Nursing Facility, : Mrs
- Mary Zapulla, RN, Director of Medical Support Phone (301) 497-1820, may contact
- Reason for leaving: Spouse received military orders, relocated to Fort Hood, Texas
- Job Duties: Medical Staff consisted of (4) Physicians, (2) Nurses, (2) Lab personnel, (1) Radiologist, (2) Medical Assistants, and (3) Front Office Personnel
- Function as charge nurse as needed, supervising (1) RN/LVN, and (2) Medical Assistants
- Maintained professional and technical knowledge by attending staff meetings, educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies
- Comprehensive knowledge of the Centers for Disease Control and Prevention Sexually Transmitted Disease treatment protocols and guidelines
- Track and report active cases to Department of Health as appropriate
- Broad knowledge of the Centers for Disease Control and Prevention of infectious diseases and treatment protocols and report to Department of Health as appropriate
- Utilize computer software applications including Microsoft Word, Excel, and Outlook
- Document assessments using computer data entry system, Meditech’s 5.0 Health Care Information System (HCIS)., Mrs
- Kay Barthgener, DON Telephone: (254) 699-5051, may contact
- Reason for leaving: Spouse received military orders to Fort Sam Houston, Texas
- Job Duties: Supervised 1 LVN (Licensed Vocational Nurse), 3 GNA (Geriatric Nursing Assistants)
- Sherrie Torrell Pruitt (Resume continued)Page 4
RN Appeals Analyst
Blue Cross Blues Shield, Palmetto GBA, Jurisdiction JJ
08.2016
- (rehire from 1996), Website: www.PalmettoGBA.com rehire (current total employment time 8 years, 11 months, Performs medical review and investigation of claims, including complex claims, to determine medical necessity and appropriateness, in accordance with company and Center for Medicare & Medicaid Services (CMS) guidelines, client needs, and legislative requirements
- Responsible for the analysis, research, and completion of standard appeals within the company
- Participates in continuing education initiatives and developmental goals
- Research and investigate all aspects of the member and provider appeals and grievances, complaints to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), member and provider contract provisions, State and/or Federal requirements, BCBSA guidelines and/or other mandated requirements (e.g., NCQA Standards, Current Procedural Terminology (CPT), ICD-9, ICD-10, and Healthcare Common Procedure Coding System guidelines (HCPCS), as applicable
- Handle, access, and protect sensitive patient data, medical records, Protected Health Information (PHI) and Personally Identifiable Information (PII) to process and review claims
- Investigate member and provider appeals by reviewing applicable resources (i.e., CMP, CMS guidelines, CPT coding guidelines, Reconsideration/Appeal Manual, contract provisions, legislation, BCBSNC management, and/or National Committee for Quality Assurance (NCQA) requirements
- Performs Clinical reviews on medical necessity and billing support issues in relation to appeals, arbitration and litigation according to guidelines of Center for Medicare & Medicaid Services (CMS)
- Consult and communicate with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented
- Review, analyze, and make determinations on provider requests for increased payments related to coding and/or bundling issues
- Communicate findings of analysis and documentation to appropriate medical staff
- Initiate claim adjustments on individual cases when necessary and follow and track until completion
- Initiate and direct planning related to project development of project objectives, expected outcomes, resource requirement, time metrics, and evaluation strategies
- Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by regulatory mandates and legislation
- Audit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education, and training to individual employees to ensure compliance with mandates
- Review press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns
- Work with word processing (Microsoft Office, e.g., Excel spreadsheet, PowerPoint presentation, and MS Word) for developmental goals and learning goals for training staff
- Knowledge of coding, claims, and billing processes with the ability to work independently, as well as with a team.
Supervisor/Manager
Georgetown Health Care
01.2000
- Theresa Goodloe, RN Phone: 512-354-4786, yes may contact
- Reason for leaving: Spouse job relocation in South Carolina
- Job Duties:
- Responsible for performing precertification, prior approvals, concurrent and retrospective reviews, and coordination of discharge planning
- Tasks are performed within the RN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets (InterQual)
- Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery
- Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services
- Determines medical necessity and appropriateness of services using clinical review criteria
- Accurately documents all review determinations and contacts providers and members according to established timeframes
- Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director
- Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director (Medical Affairs)
- Protects data (Protected Health Information (PHI) and Personally Identifiable Information (PII) from unwarranted access
- Appropriately identifies potential cases for Care Management programs
- Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum
- Communicates appropriate information to other staff members as necessary/required
- Participates in continuing education initiatives
- Collaborates with Claims, Quality Management and Provider Relations Departments as requested., Mrs
- Terri Watson, RN Phone: 512-512-7216, yes may contact
- Reason for leaving: Accepted a work from home position
- Job Duties:
- Upon direction from the Office of Inspector General (OIG), obtain and review medical records to determine compliance with Medicaid medical and program policies
- Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions
- Analyzes statistical, historical data, and reports data and review findings along with recommended cutbacks or denials of services for each claim detail on spreadsheet
- Compose narrative summary of record review findings and write education or recoupment letters as directed by OIG
- Perform OIG-directed actions for case disposition which may include initiating claims payment recoupment of denied or cutback services; conducting provider education; or performing prepayment review and adjudicating claims based on results of record review
- Document and track provider case review activities and case disposition, and prepayment review activities
- Perform review of cases referred from Texas Attorney General’s Office and/or other agencies and prepare report of findings
- Review and process appeals upon direction from OIG
- Prepare reports/deliverables of SUR (Surveillance and Utilization activities
- Use computers to enter, access, or retrieve data while integrating, identifying, and resolving problems or refer issues appropriately
- Communicate effectively and adapt to the needs of internal and external customers
- Assure compliance with regulatory, contractual and accreditation entities
- Implement expertise in clinical operations, develops, and/or oversees the development of information related to patient care while exercising strategies in the treatment that impacts health status outcomes, clinical endpoints, enhance clinical care
- Maintain strict adherence to confidentiality and security policies and procedures., Mrs
- Terri Watson, RN Phone: 512-334-1765, yes may contact
- Reason for leaving: This employer has been the QIO (Quality Improvement Organization) contract for the state of Texas for the past 30 years
- Due to government changes with Medicare, they could not bid on Medicare contract with CMS, so the position/dept will come to so close in July 2014
- You may contact and confirm this with Human Resources or with manager of department
- Job Duties:
- Performs various types of medical record reviews by specific contracts as assigned
- Coordinate case review process in accordance with guidelines and regulations
- Communicate via telephone with Medicare beneficiaries/representatives, healthcare providers (ex
- Case managers, MDS coordinators, physical/occupational therapists, or social workers), and physicians using excellent communication skills while documenting accounts of Medicare beneficiary stay at variety of nursing care facilities to include Hospitals, Skilled Nursing Facilities, Home Health, Hospice, Psychiatric, and CORF (Comprehensive Outpatient Rehabilitation Facilities) for the state of Texas
- Formulate review questions based on the medical record, then refer cases to physician reviewers and aid as needed
- Review physician determinations and seek clarification when necessary
- Prepare correspondence to Medicare beneficiaries/representatives, healthcare providers and physicians using effective written communication techniques in required time frames
- Utilize McKesson InterQual software to determine inpatient criteria for acute hospital admissions
- May review written complaints to determine if criteria are met for quality-of-care review and discharges to lower level of care
- Perform case review data entry in required time frames and assure compliance with regulatory, contractual and accreditation entities., Website: http://www.stdavids.com/locations-facilities/georgetown-hospital.aspx
- Supervisor: Mr
- Ron Weaver, Telephone: (512) 943-3000, may contact
- Reason for leaving: Spouse received military orders to Fort Sam Houston, Texas
- Job Duties: Float between Medical-Surgical & In-patient Rehabilitation Units
- Determine FIM (Functional Independence Measures) in measuring the level of a patient's disability and indicates how much assistance is required for the individual to carry out activities of daily living
- Participate in staff meetings with a collaborative team of Physicians, Occupational & Physical Therapists, and all other medical personnel to establish a care plan to determine the special need(s) of patients.
Utilization Management RN
Valence Healthcare
03.2016 - 07.2016
Utilization Review RN Analyst
TMF Health Quality Institute
08.2014 - 03.2016
RN Review Coordinator
TMF Health Quality Institute
11.2013 - 08.2014
Charge Nurse
PRN
06.2013 - 01.2014
Registered Nurse(Relief Charge Nurse
PRN Float
05.2012 - 11.2013
- UNIT: 2 WEST (Medical-Surgical with Telemetry/Adults & Pediatrics Unit
Registered Nurse
02.2011 - 09.2012
- UNIT: 5th Floor & 2nd floor (Ortho/Surgical & Medical-Surgical with Telemetry)
Charge Nurse
Future Care Management
05.2009 - 09.2009
- Futurecarehealth.com/locations/lochearn
Charge Nurse
Glen Burnie Health & Rehabilitation
08.2007 - 01.2009
- Website: http://www.savaseniorcare.com/
- Supervisor: Mrs
- Dawn Edwards, RN, Director of Nursing Phone (410) 766-3460, may contact
- Reason for leaving: Spouse received military orders, relocated to Fort Hood, Texas
- Job Duties: Supervised: LVNs and (3-4) GNAs (Geriatric Nursing Assistants)
- Total capacity on unit: 42 bed unit
- Float between Long Care sub-acute, Alzheimer’s, and skilled nursing facility units.
Charge - Registered Nurse
Patient First Urgent Care Clinic, Corridor Marketplace
12.2007 - 12.2008
Registered Nurse II, Weekend Charge Nurse
Northeast Methodist Hospital
09.2005 - 07.2006
- Website: http://sahealth.com/locations/northeast-methodist-hospital/
- Supervisor: Mrs
- Lainey Klingeman, RN, phone: (210)757-7000 or (210) 650-4949, may contact
- Reason for leaving: High risk pregnancy (per medical orders) and spouse received military orders to relocate to Fort Meade, Maryland
- Job Duties: Assign nursing assignments of patients and assign care and oversee care of Licensed Practical Nurses Floated between Medical, Surgical, and Inpatient Rehabilitation units
- Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations
- Resolves patient problems and needs by utilizing multidisciplinary team strategies
- Determine FIM (Functional Independence Measures) in measuring the level of a patient's disability and indicates how much assistance is required for the individual to carry out activities of daily living
- Participate in weekly staff meetings with a collaborative team to establish plan of care
- Participate in staff meetings with a collaborative team of Physicians, Occupational & Physical Therapists, and all other medical personnel to establish a care plan to determine the special need(s) of patients.
Staff Nurse I
03.2005 - 07.2005
Staff Nurse
Indian Oaks Retirement Home
12.2004 - 07.2005
- Alzheimer’s Unit (Special Care Unit
Education
Baccalaureate in Nursing - RN-BSN
Fort Hays State University
Hays, Kansas01.2011
Associate in Applied Science - Nursing-ADN
Central Texas College
Killeen, Texas01.2004
Diploma in Data Processing -
Phillips Junior College
Columbia, South Carolina01.1991
Skills
- Public Speaking
- Medical Terminology
- Customer Service
- Office Equipment
- Computer Software
- Typing 60 WPM
Awardsachievementsskills
- Health Occupations Students of America competing in District, State, and National competitions in Public Speaking and Medical Terminology, 1986-1988
- National Honor and National Vocational Honor Society, 1986-1988
- Red Cross and Hospital Volunteer, 1987-1988
- Employee of the Month (Sallie Mae), 05/00 and 02/01
- Current member of the American Nursing Association (ANA)
- Excellent knowledge of office equipment and customer service experience, Type 60+ WPM
Timeline
RN Appeals Analyst
Blue Cross Blues Shield, Palmetto GBA, Jurisdiction JJ
08.2016
Utilization Management RN
Valence Healthcare
03.2016 - 07.2016
Utilization Review RN Analyst
TMF Health Quality Institute
08.2014 - 03.2016
RN Review Coordinator
TMF Health Quality Institute
11.2013 - 08.2014
Charge Nurse
PRN
06.2013 - 01.2014
Registered Nurse(Relief Charge Nurse
PRN Float
05.2012 - 11.2013
Registered Nurse
02.2011 - 09.2012
Charge Nurse
Future Care Management
05.2009 - 09.2009
Charge - Registered Nurse
Patient First Urgent Care Clinic, Corridor Marketplace
12.2007 - 12.2008
Charge Nurse
Glen Burnie Health & Rehabilitation
08.2007 - 01.2009
Registered Nurse II, Weekend Charge Nurse
Northeast Methodist Hospital
09.2005 - 07.2006
Staff Nurse I
03.2005 - 07.2005
Staff Nurse
Indian Oaks Retirement Home
12.2004 - 07.2005
Supervisor/Manager
Georgetown Health Care
01.2000
Sub-Contractor
TMHP, Texas Medicaid and Healthcare Partnership
Skilled Nursing Facility/Rehabilitation
Cornerstone Gardens Health Care and Rehabilitation
Supervisor
Seton Medical Center Harker Heights, Central Texas Expressway
Supervisor
Adventist Health Care System
Baccalaureate in Nursing - RN-BSN
Fort Hays State University
Associate in Applied Science - Nursing-ADN
Central Texas College
Diploma in Data Processing -
Phillips Junior College
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