SHIRLEY SIMS, RN, MSN, CCM
Belgrade,MT
Summary
Seasoned Utilization Review Nurse considered a critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare guidelines. Known for having great rapport with providers and insurance carriers. Reliable individual bringing 30 years of experience in healthcare environments. Maintains positive relationships with MCO case managers and providers. Remains polished and calm under extreme stress. Skilled at improving processes, maximizing productivity and reducing costs to achieve sustainable outcomes. Skilled with multiple EMR such as Cerner, Epic, Medi-Tech, Teams, SharePoint, Excel and other Microsoft platforms. Excellent communication skills. Advanced skills in InterQual and Milliman criteria. Certified in Case Management with Discharge Planning and Transitional Care skill sets.
Overview
20
20
years of professional experience
1
1
Certification
Work History
RN Utilization Review Case Manager
TriState Memorial Hospital
Clarkston, Washington
03.2021 - Current
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
- Negotiated with suppliers and vendors to procure medical equipment, supplies and services.
- Completed initial assessments of patients and family to determine and address individual home care needs. ·
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Supervised and maintained all utilization review documentation through Meditech.
- Submitted cases to Patient Access Manager for criteria failures and helped facilitate resolutions and approvals.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed prior authorization review of services requiring notification.
- Performed admission reviews based for medical necessity based upon InterQual specification.
Case Manager II
Vanderbilt University Medical Center
Nashville, Tennessee
10.2020 - 02.2021
- Addressed disruptions in patient care, including delays in discharge, postponed procedures and discharge equipment unavailability.
- Managed support services and fostered communication among social workers, Physical and Occupation therapists, hospital staff and patients.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
- Worked with different disciplines to provide cohesive care to patients.
- Consulted with clinicians to devise and manage effective ongoing care plans for at-risk patients.
- Took active role in patient and family planning process, detailing instructions and responding appropriately and effectively to questions and concerns.
- Partnered with physicians, social workers, activity therapists, nutritionists and case managers to develop and implement individualized care plans and documented all patient interactions and interventions in electronic charting systems.
- Evaluated treatment plans against individual goals and healthcare standards.
- Updated patient charts using Epic and Aidin software with data such as medications to keep records current and support accurate treatments.
Registered Nurse Case Manager
MedPartners
Clarkston, WA
09.2019 - 05.2020
- Authored initial assessments of patients and family to develop plans for individual post acute care needs.
- Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
- Advocated for patients by communicating care preferences to practitioners, ensuring interventions met treatment goals and identifying insurance coverage.
- Performed Utilization Review to ensure met Interqual guidelines for Acute Care and Treatment, verified OBS and management of 2 midnight rule.
- Use of Cerner for documentation and Interqual software.
- Clear communication skills with interdisciplinary team on goals of discharge to Post Acute care and treatment, OP services and more.
- Contract Case Manager for MedPartners
RN Case Manager
MedPartners
Jackson, MS
05.2019 - 08.2019
- Audited charts and reviewed clinical documents to verify accuracy.
- Managed support services and fostered communication among social workers, Physical, Occupational and Speech therapists, hospital staff and patients.
- Increased referral rates by providing excellent service and building meaningful relationships with patients and caregivers.
- Educated patients and caregivers on healthcare protocols and processes.
- Managed care from admission to discharge, including patient assessments, care planning, health educations and discharging support to provide comprehensive care to over 35 patients daily.
- Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
- Provided home healthcare providers with training, guidance, support and supervision to achieve objectives.
- Took active role in patient and family planning process, detailing instructions and responding appropriately and effectively to questions and concerns.
- Used Meditech to maintain database of relevant information for practitioners to access and coordinate patient care.
- Managed and streamlined referral queues of up to 35+ by efficiently prioritizing patients and clearing insurance obstacles.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Reduced care costs without sacrificing quality through effective service coordination and multidisciplinary collaboration.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
- Coordinated care of injured workers by liaising with hospital staff to organize treatments and program resources.
RN Case Manager
Medpartners
Henderson, NV
02.2019 - 04.2019
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Educated patients and loved ones about different treatment options and outside care approaches, reducing burden on hospital resources.
- Reduced care costs without sacrificing quality through effective service coordination and multidisciplinary collaboration.
- Consulted with clinicians to devise and manage effective ongoing care plans for at-risk patients.
- Took active role in patient and family planning process, detailing instructions and responding appropriately and effectively to question and concerns.
- Partnered with physicians, social workers, activity therapists, nutritionists and case managers to develop and implement individualized care plans and documented all patient interactions and interventions in electronic charting systems.
- Addressed disruptions in patient care, including delays in discharge, postponed procedures and discharge equipment unavailability.
- Evaluated treatment plans against individual goals and healthcare standards.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
- Reported plans, findings and results to employers and insurance carriers.
- Updated patient charts using Midas and Interqual with data such as Utilization Initial and Concurrent Review to keep records current and support accurate discharge plans.
- Managed case load of 35 patients, providing comprehensive, discharge planning and community-based care.
- Contract Case Manager for MedPartners
NCLEX-RN Exam Faculty
KAPLAN UNIVERSITY
Ft. Lauderdale, Florida
03.2018 - 08.2021
- 3 day post graduation prep for NCLEX license exam.
- Seasonal only.
- Training strategies of critical thinking to pass exam first attempt.
- Requires excellent attitude, great communication skills and ability to assist students to problem solve and use critical thinking skills to insure success.
- Achieved 95% passing rate per class.
- Respond to student and faculty requests via telephone and email.
Director Of Clinical Operations, Govt. Programs
Health Care Services Company (HCSC)
Helena, MT
12.2015 - 12.2017
- Directed day-to-day operational activities of Utilization, Care/Case Management, and Disease Management for 30K + members of HELP (Health and Economic Livelihood Partnership) coordination with DPHHS Montana.
- Grew and initiated this team from ground up for MT HELP and HMK programs within HCSC.
- Directed Nursing and ad hoc staffing in entry of Health Assessments, telephonic outreach, admission into DM programs and follow up.
- Attend monthly meetings with DPHHS.
- Performed initial client assessment and analysis to begin research process.
- Copied, logged and scanned supporting documentation.
- Researched and updated all required materials needed for firm and partners.
- Created quarterly newsletter for participants.
- Verified data integrity and accuracy.
- Produced ad hoc reports and documents for senior team members.
- Analyzed departmental documents for appropriate distribution and filing.
- Responded to customer requests via telephone and email.
- Implemented marketing strategies which resulted in 8% growth of customer base.
- Education of staff to in use of program software, outreach and engagement of participants for outreach.
- Management and 10-12 staff with performance review monthly and final yearly review.
- Community outreach through wellness programs, program descriptions and assistance with enrollment into programs.
Director Of Case Management
Bozeman Deaconess Health Services
Bozeman, MT
01.2012 - 08.2015
- Directed and Managed day to day operations of Case Management Department of a 85 bed hospital.
- Created and directed ED program for CM to perform real time assessments and assist/educate/advise physicians in transitional options to present unnecessary admissions to the hospital.
- Directed integration of the department to work with physicians and hospitalists in requirements of Medicare, Medicaid and Managed Care in meeting admission criteria, managing Observations and assisting in timely discharge planning with family and community for safe discharges. Expertise in InterQual and Milliman Criteria.
- Developed Policies and Procedures to support provision of Case Management Department to integrate with facility mission, vision and goals.
- Creative "out-of-the-ox" thinking and options for difficult discharge scenarios.
- Consistent focus on improving department, education of staff and provision of improved outcomes.
- Developed initial orientation for all new staff and ongoing education for primary staff.
- Facilitate and participate in key committees, medical staff committees and other work groups as needed.
- Collaborated with Medical Records, Billing, Coding and Clinical Documentation Specialists as needed to improve workflow and reimbursements.
- Managed Appeals, appeal letters and necessary documentation for reimbursement.
- Advocate for patients/families, difficult ethical cases, supported nursing and CM activities in positive results of care initiatives.
- Promote interdisciplinary meetings using effective communication, collaboration and coordination with participating departments.
- Use of analytical and critical thinking to find creative and out of the box solutions for difficult patient management and discharge scenarios.
- Produced ad hoc reports and documents for senior team members.
- Copied, logged and scanned supporting documentation.
- Verified data integrity and accuracy.
- Integrated new software of InterQual, staff training and computerized use of criteria for staff. This directly decreased time spent to determine if client met or did not meet admission or observation criteria.
- Worked with staff on prevention of re-admissions and strategies for implementation in working with staff physicians to reduce risk and promote success in transition of care.
National ECF Supervisor
Cigna Healthcare
Atlanta, GA
11.2005 - 12.2011
- Began as a ECF (Extended Care Facility) Inpatient Case Manager with case load of 45-70 clients to manage transitions sent from Acute Care Hospitals to secondary IP facilities such as LTAC, Acute Rehab, Skilled Nursing Facilities, Long Term Care, Home Health Care or OP rehabilitation.
- After two years was promoted to Supervisor of ECF in Southeast Region over 8 staff. Later with separation of direct IP Acute Care Case Managers and ECF Case Managers - began supervising 10-12 staff nationally for contracts, ACO, and managed care. Managed based on employer contracts, worked directly with facilities and hospitals regarding contracts, negotiating rates, creating contract agreements for ongoing care of long term cases and SNF settings.
- Evaluated staff performance monthly, quarterly and annually.
- Regular staff meetings monthly to discuss new contracts, workflows and staffing issues/concerns.
- Supervision was done through telecommunication and phone as staff were work at home.
- Develop policies and procedures for staff support.
- Assisted contracting with new potential facilities, services and recommended changes for problem services.
- Assisted staff with high case loads.
- Assisted staff with difficult and challenging cases where facilities could not locate accepting facilities for long term or critically ill patients.
- Prepared and developed reports for managing department in fiscally responsible manner.
- Built positive and effective business relationships with Special Accounts, facilities, managers and staff.
- Excellent communication skills and problem solving capacity to work effectively with others in identification of needs and resolution of issues.
- Program development for prevention of re-admissions.
- Analyzed departmental documents for appropriate distribution and filing.
- Responded to customer requests via telephone and email.
- Verified data integrity and accuracy.
- Copied, logged and scanned supporting documentation.
Medical Floor Case Manager
Northside Hospital
Atlanta, GA
11 2004 - 1 2005
- Multiple Unit case management chart review.
- Met with families for discharge planning and appropriate transition of care placements.
- Interacted daily with HHC agencies, SNF, Acute Rehab, LTAC and other facilities for placement of post-acute patients/clients.
- Review of chart documentation for determination of IP or OBS criteria.
- Interdisciplinary meetings with physician and staff for review of documentation to support continued stay reviews, initial reviews and coordination of care and benefits.
- Performed frequent research, calls and negotiation for patient admissions to secondary IP facilities for ongoing care.
- Expertise in Rehabilitation with CRRN certification.
- Participated in continuing education in InterQual, Milliman, Case Management issues and concerns and disease management.
- Focus on re-admission prevention.
- Training on assisting with discharge planning for multiple cultures and understanding the dynamics of cultural expectations and family participation in care.
- Daily case load of 35 or more patients, inclusive of phone calls and faxing of requests for authorization and placement.
- Worked at two campuses - Main and Forsyth.
- Expertise with trauma and ICU cases.
- Obtained documents, clearances, certificates and approvals from local, state and federal agencies.
- Copied, logged and scanned supporting documentation.
Education
M.S - Nursing - Specialty in Case Management
American Sentinel University
Aurora, CO2015
Associate of Science - Nursing
Saint Vincent's School of Nursing
Birmingham, AL1982
Skills
MEMBERSHIPS Case Management Society of America, Sigma Theta Tau, and Golden Key Honor Society
- Case Management
- HIPAA Compliance
- Discharge Planning
- Managed Care
- Patient Care Coordination
- Milliman / InterQual
- Cerner / Epic / Other EMR
- Word, Power Point, Excel, Office 365
- Appeals / Denials/ Prior Auth
- Interpersonal and written communication
- Process implementation
- Patient Information Collection
Certification
MEMBERSHIPS Case Management Society of America HCPro, CCM (Certified Case Manager) Current through 2025 .
Languages
English - native language]
Additional Information
- AWARDS , Sigma Theta Tau March 2015 - Present Golden Key Honor Society March 2014 - Present St. Vincent's School of Nursing Senior Honor Chaplain August 1981 - May 1982
Timeline
RN Utilization Review Case Manager
TriState Memorial Hospital
03.2021 - Current
Case Manager II
Vanderbilt University Medical Center
10.2020 - 02.2021
Registered Nurse Case Manager
MedPartners
09.2019 - 05.2020
RN Case Manager
MedPartners
05.2019 - 08.2019
RN Case Manager
Medpartners
02.2019 - 04.2019
NCLEX-RN Exam Faculty
KAPLAN UNIVERSITY
03.2018 - 08.2021
Director Of Clinical Operations, Govt. Programs
Health Care Services Company (HCSC)
12.2015 - 12.2017
Director Of Case Management
Bozeman Deaconess Health Services
01.2012 - 08.2015
National ECF Supervisor
Cigna Healthcare
11.2005 - 12.2011
Medical Floor Case Manager
Northside Hospital
11 2004 - 1 2005
M.S - Nursing - Specialty in Case Management
American Sentinel University
Associate of Science - Nursing
Saint Vincent's School of Nursing