Tantanisha Mitchell
Riverview
Summary
Registered Nurse with excellent communication, management and client relationship building skills seeking an opportunity to build, lead and/or support Educational, Operational and Quality Improvement initiatives within an organization. Experience includes facilitation of successful CMS audits; NCQA and URAC re-accreditation surveys including, but not limited to, continual monitoring and audit preparation. Additional expertise with management and supervision of clinical and non-clinical staff; experience with case management, utilization review/management; design, development and facilitation of clinical and non-clinical instruction while maintaining a strong focus on quality and comprehensive management of nursing care.
Experienced in utilization management nursing, with a strong background in coordinating patient care, ensuring optimal use of healthcare resources and maintaining compliance with healthcare policies. Skilled at multitasking, decision making, and communicating effectively across multidisciplinary teams to optimize patient outcomes. Previously implemented process improvements that contributed to enhanced efficiency and quality of patient care services.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Utilization Management Nurse
Advent Health
03.2021 - Current
- Performs clinical performance improvement activities
- Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load
- Thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials
- Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues
- Works independently and exercise sound judgment in interactions with physicians, payors, patients and their families
Clinical Supervisor
Cohere Health
Tampa
06.2020 - 02.2021
- Provide day to day clinical oversight of RN Reviewer team for day-to-day operations to include coaching, mentoring, quality auditing and candidate selection
- Work cross functionally across remote teams to meet objectives and metrics established by senior leadership
- Oversight of quality improvement initiatives to ensure medical necessity reviews were completed in compliance with state and federal requirements, as well as accreditation entities
Manager of Quality Improvement, Accreditation and Training
EXL Service
Tampa
06.2018 - 11.2019
- Responsible for development and implementation of Organizational wide Quality Improvement program designed to effectively monitor, improve and advance quality of care according to standards set forth by NCQA, URAC and CMS
- Oversight of training program which included Onboarding, job readiness and skill building for the entire organization
- Oversight of annual member and practitioner satisfaction survey process to include data analysis, action plan development, client report preparation and continual assessment
- Managed performance of training staff to include hiring, mentoring, dismissing or separation and professional development of staff
- Assisted the SAVP of Care Management Operations with advancing QI Program objectives and evaluated QI Initiatives against established goals to identify trends, barriers, opportunities, and improvement activities
- Development, monitoring and resolution of corrective action plans in response to clients, accreditation agencies and regulatory bodies such as NCQA, CMS and URAC
- Successfully lead Accreditation activities to obtain certification and/or maintain NCQA, URAC and CMS external audits
- Implemented an internal auditing team in preparation of upcoming external audits from Health Plans and Accreditation entities
Clinical Analyst III-Accreditation and Audit
CareCentrix
Tampa
09.2016 - 06.2018
- Facilitation of customer delegation oversights audit for all Carecentrix Health plan partners and various external Accreditation entities to ensure compliance with Regulatory and Contractual requirements
- Conducted internal audits to identify risk and opportunities for improvement within the UM Organization
- Monitored open corrective action plans to ensure compliance with requirements and provide feedback to drive change within the business operations
- Interfacing with internal Business Leaders as well as external auditors during presentation and facilitation of various audits, including NCQA, URAC, CMS, etc
Sr. Clinical Trainer – Learning and Development
CareCentrix
Tampa
03.2015 - 09.2016
- Conducted training needs analysis to determine the need for clinical training within the organization
- Analyze, develop, design and facilitation of all clinical training to support meeting and exceeding health plan requirements, URAC and NCQA standards, new business implementations, system enhancements, GAP and refresher training
- Provide reporting feedback to business leadership to support return on investment
Clinical Supervisor
CareCentrix
Tampa
01.2013 - 03.2015
- Manage team of virtual and in office clinicians completing utilization management functions for various health plans
- Coach, mentor and train nurses within the UM organization to ensure clinicians are meeting and exceeding expected team goals
- Liaison with internal departments to create and streamline processes while upholding URAC, NCQA and individual health plan quality standards
- Assisted with the creation of policies and procedures within the UM department
Utilization Management Nurse
Inetico/Ineticare
Tampa
04.2012 - 09.2012
- Utilization management and precertification of inpatient/outpatient medical procedures including surgical procedures, diagnostic procedures, DME and length of stays
- Determine medical necessity according to specific MCG criteria and refer to Physician Reviewers when appropriate
- Render determination within URAC guidelines
Utilization Review Nurse
Coventry Workers Comp Division
Tampa
08.2010 - 03.2012
- Utilization management and review of Workers Comp cases to determine the medical necessity for specific accounts according to specific guidelines, such as but not limited to Official Disability Guidelines
- Timely render determinations within specific turnaround times and refer to Physician Advisors when appropriate
- Consistently met URAC guidelines
Education
Master’s Degree - Healthcare Informatics
Excelsior University
03.2025
Associate's Degree - Nursing
Fortis College
Tampa, FL12.2012
High School Diploma -
St Petersburg High School
St Petersburg, FL12.1993
LPN Certificate Program -
Galen Health Institute
St Petersburg, FLSkills
- Interpersonal and written communication
- Training staff
- Professionalism
- Problem-solving abilities
- EMR / EHR
- Case management
- Strong clinical judgment
- Manage cases
- Quality improvement
- Regulatory compliance
- Epic systems
- Data analysis
- Team leadership
- Effective communication
Certification
- Registered Nurse, RN9356145, Florida, 07/20
- ATD Certified Professional in Designing Learning, 03/15
- MCG Certified Care Guidelines Specialist, Utilization Management
References
Available upon request
Timeline
Utilization Management Nurse
Advent Health
03.2021 - Current
Clinical Supervisor
Cohere Health
06.2020 - 02.2021
Manager of Quality Improvement, Accreditation and Training
EXL Service
06.2018 - 11.2019
Clinical Analyst III-Accreditation and Audit
CareCentrix
09.2016 - 06.2018
Sr. Clinical Trainer – Learning and Development
CareCentrix
03.2015 - 09.2016
Clinical Supervisor
CareCentrix
01.2013 - 03.2015
Utilization Management Nurse
Inetico/Ineticare
04.2012 - 09.2012
Utilization Review Nurse
Coventry Workers Comp Division
08.2010 - 03.2012
Master’s Degree - Healthcare Informatics
Excelsior University
Associate's Degree - Nursing
Fortis College
High School Diploma -
St Petersburg High School
LPN Certificate Program -
Galen Health Institute
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