Theresa Ramlochan
Albany
Summary
Dynamic RN Case Manager with extensive experience at Aetna, excelling in case management and healthcare team collaboration. Proven ability to optimize member benefits and ensure high-quality care through effective utilization review. Skilled in pharmacology and communication, diving successful outcomes and promoting diversity, equity, and inclusion within the organization
Professional with strong background in nursing and case management, specializing in patient advocacy and care coordination. Adept at developing comprehensive care plans, managing complex medical cases, and working collaboratively with multidisciplinary teams to achieve optimal patient outcomes. Known for adaptability, reliability, and results-focused approach in dynamic healthcare environments. Skilled in patient assessment, discharge planning, and resource utilization.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Aetna
01.2013 - Current
- Responsible for collaborating with healthcare providers and members in order to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Responsible for ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources.
- A member of the Diversity, Equity & Inclusion (DEI)Committee, completed formal Diversity, Equity & Inclusion seven-hour certification. A member of the Employee Engagement Committee
- Presented DEI power point presentation to Upper embracement of diversity, equity and inclusion within the organization
- Covered for the Team Lead and been the point of contact for Delaware Valley ACO (DVACO) clinical liaison
- Aetna Team Lead 2020 – 2022
- Experience with reviewing High Cost Reports, Engaged of Reach Reports, Productivity Reports, Weekly Active Case Reports, Experience in daily case assignment to case managers
RN Case Manager Level 3
Wellpoint (BCBS)
01.2010 - 01.2013
- Responsible for collaborating with healthcare providers and members in order to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Responsible for ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
- Delaware County Public Health Nursing
RN
Dialysis Oneonta Specialty Services
06.2007 - 10.2008
O’Connor Hospital
08.2006 - 06.2007
LPN
Country Side Care Center
07.2005 - 08.2006
Clerk
SUNY Delhi College
01.2003 - 01.2004
Education
A.A.S. Degree - Nursing major (RN)
State University of New York
Delhi, NY05.2006
B.S. - Nursing
State University of New York
Delhi, NY05.2014
Skills
- Pharmacology
- Analysis
- Documentation
- Pre- and Post-operative care
- Patient and family teaching
- Cost savings
- CNA supervision
- Therapeutic skills
- Knowledgeable with OASIS
- Communication
- Healthcare team collaboration
- Utilization Review
- Disease process teaching
- Case management and utilization review experience
- Disease management
- Experience with workflows
Certification
- Certification in DEI (Diversity, Equity & Inclusion) In The Work Place 2021
- Member of Employee Engagement Survey Committee (EESC) 2019 – Present
- Member of Diversity Awareness Workgroup 2021
Timeline
Aetna
01.2013 - Current
RN Case Manager Level 3
Wellpoint (BCBS)
01.2010 - 01.2013
RN
Dialysis Oneonta Specialty Services
06.2007 - 10.2008
O’Connor Hospital
08.2006 - 06.2007
LPN
Country Side Care Center
07.2005 - 08.2006
Clerk
SUNY Delhi College
01.2003 - 01.2004
B.S. - Nursing
State University of New York
A.A.S. Degree - Nursing major (RN)
State University of New York
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