Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Shonda Aires

Tampa,FL

Summary

Licensed Practical Nurse with extensive experience and knowledge in Utilization Management. Detail-oriented with strong organizational and time management skills. Quality focused and seeking a position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.

Overview

9
9
years of professional experience
1
1
Certification

Work History

Appeals Nurse Reviewer

Centene Corporation
07.2018 - Current
  • Reviewing 1st and 2nd level provider appeal requests (Medical & Behavioral Health) utilizing criteria based systems of InterQual, Milliman (MCG), and Organizational guidelines.
  • Abstraction and documentation of pertinent clinical information to determine medical necessity of requested services.
  • Referring cases to Medical Director for review and final determination for cases not meeting medical necessity or complex cases.
  • Maintaining state regulatory guidelines in turn-around-times for decisions.
  • Assisted with resolution of escalated and expedited cases; resource for non-clinical staff.
  • Served as preceptor to new nurse reviewers.

Retrospective Review Nurse

WellCare
03.2016 - 07.2018
  • Reviewed medical records for services rendered in emergency room to validate appropriateness of care, level of care, and quality of care.
  • Analyzed findings against PLP (Prudent Lay Person) guidelines to render decisions; escalate cases to Medical Director for further review for final determination.
  • Identified misuse of emergency room utilization resources.

Concurrent Review Nurse

Health Integrated
01.2015 - 11.2015
  • Performed initial and continued stay reviews to determine medical necessity and appropriateness for inpatient admissions by utilizing clinical skills, applying criteria-based guidelines: Milliman (MCG) and Health Plan policies.
  • Monitored progress of discharge planning to ensure members receive timely, accurate, and cost-effective services post discharge.
  • Elevated cases to Medical Director for review for decertification and extensions of continued stay.
  • Assisted Case Managers/discharge planners with facilitating discharge needs, such as SNF, long term care, home health, DME.

Education

Some College (No Degree) - Practical Nursing

Pinellas Technical Education Center
St. Petersburg, FL

Skills

  • Nursing Documentation
  • Utilization review
  • Medical record review
  • Clinical judgment
  • Direct Patient Care
  • Analytical Thinking
  • Problem-solving abilities
  • Professionalism
  • Organizational Skills
  • Multitasking Abilities
  • Time management

Certification

Compact Nursing License.

Timeline

Appeals Nurse Reviewer

Centene Corporation
07.2018 - Current

Retrospective Review Nurse

WellCare
03.2016 - 07.2018

Concurrent Review Nurse

Health Integrated
01.2015 - 11.2015

Some College (No Degree) - Practical Nursing

Pinellas Technical Education Center

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Shonda Aires