Tamra Cox
Roseville,CA
Summary
Seasoned Utilization Review-Care Manager from HealthNet Federal Services, adept in policy authorship and IT project leadership. Excelled in creating impactful training programs and enhancing authorization systems, showcasing Microsoft 365 mastery and collaborative prowess. Proven track record in improving healthcare delivery through meticulous policy and procedure management.
Overview
35
35
years of professional experience
1
1
Certification
Work History
Utilization Review-Care Manager I, II and III
HealthNet Federal Services
Roseville , California
08.2004 - Current
- Performed preauthorization reviews.
- Provided transition of care from inpatient through discharge, with follow-up post-discharge care assessment.
- Key participant in the Medical Management Policy and Procedure Center of Leadership.
- Responsible for authoring and updating all policies and procedures for the entire department.
- Lead auditor and author of the audit tool used by the entire team.
- Main User Acceptance Testing (UAT) lead for all computer applications used by all Medical Management (Case Management, Disease Management, Outpatient UM, and Inpatient UM), including writing test scripts for quality assurance (QA) and UAT testing projects.
- Continued collaboration with the Program Data Management (PDM) team on Single Case Agreements (SCA) with providers (individual, group, and facility providers).
- Responsible for claims, authorization discrepancies, and overturning authorizations based on successful appeals.
- Created a training program for new UM staff, which included an in-depth analysis of all TRICARE Manuals (TPM, TRM, and TOM).
- Provided case management services for active-duty service members (ADSM) who sustain traumatic injuries or illnesses, including working with the Veterans Administration for the transition of care due to medical retirement.
- Main trainer of the authorizations system, Care Radius, for the Defense Health Administration - Great Lakes (DHA-GL).
RN-24 Hour Line
HealthNet Federal Services
Rancho Cordova , CA
01.2002 - 09.2004
- Responsible for urgent care authorizations for TRICARE beneficiaries after normal business hours.
- Collaborated with beneficiaries to find them care when they are out of the area.
- Forwarded calls to TRICARE service centers during business hours.
Operating Room RN
Sutter General Hospital
Sacramento , CA
06.1989 - 09.2000
- I worked as both a circulating nurse and a scrub nurse for all surgeries, with an emphasis on neurosurgery and urological surgery.
- ACLS and BLS certified.
- Surgery department laser calibrator and tester for all lasers used, including KTP YAG, Argon Beam, and CO2.
Education
Associate of Science - Registered Nursing Program
Sacramento City College
Sacramento, CA05-1989
Bachelor of Science - Chemistry
California State University, Sacramento
Sacramento, CA06-1987
Skills
- Information Technology Project Lead
- Inpatient UM Clinical Lead
- Policy and Procedure Author
- Warrior Care Support Program Lead
- Regular Military Treatment Facilities (MTF) conference attendees
- Microsoft 365 proficiency
- Vast TRICARE manual(s) knowledge
- InterQual and Milliman proficiency
- In-depth understanding of reimbursement methods, including PPS, Per Diem, and DRG
- Key contributor to creating and modifying the authorization system Care Radius including prioritizing all authorization adjudication rules
Certification
- CMCC-#00132519 -03/2014-Present
- CMCN- #13-1965 -10/2019-Present
- CA RN- #RN443396 -06/1989-Present
Timeline
Utilization Review-Care Manager I, II and III
HealthNet Federal Services
08.2004 - Current
RN-24 Hour Line
HealthNet Federal Services
01.2002 - 09.2004
Operating Room RN
Sutter General Hospital
06.1989 - 09.2000
Associate of Science - Registered Nursing Program
Sacramento City College
Bachelor of Science - Chemistry
California State University, Sacramento
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