
Registered Nurse with 5+ years of experience in clinical care, case management, and utilization review. Skilled in benefit coordination, medical necessity review, and chronic/complex disease management (CHF, COPD, CKD, diabetes, HTN, behavioral health). Experienced in collaborating with FQHCs and tribal health systems (Chickasaw Nation) to improve care delivery and reduce readmissions. Highly proficient in Epic EMR and experienced with HCHB EMR. Eligible to sit for the Certified Case Manager (CCM) exam.
• Conduct comprehensive clinical assessments to determine medical necessity, develop individualized care plans, and monitor progress.
• Coordinate care with FQHCs, tribal health clinics, and community health centers.
• Apply clinical criteria and policies to facilitate appropriate benefit utilization.
• Document and monitor patient progress in HCHB EMR, ensuring compliance with CMS/payer standards.
• Educate patients/families on disease self-management and medication adherence, reducing hospital readmissions.
• Delivered evidence-based care to critically ill patients with multiple comorbidities.
• Collaborated with providers to evaluate treatment options and facilitate appropriate care transitions.
• Documented care and outcomes in Epic EMR (highly proficient) for accurate and timely reporting.
• Supported hospital quality improvement initiatives, enhancing patient outcomes and adherence to standards
• Delivered evidence-based care to patients with multiple comorbiditie recovering from critical illness or surgery
• Collaborated with providers to evaluate treatment options and facilitate appropriate care transitions.
• Documented care and outcomes in Epic EMR (highly proficient) for accurate and timely reporting.
• Supported hospital quality improvement initiatives, enhancing patient outcomes and adherence to standards
Utilization Management & Coverage Determinations
Clinical Review & Benefit Coordination
Chronic & Complex Case Management
Quality Improvement & Closing Care Gaps
Epic (Highly Proficient) & HCHB EMR
Patient & Family Education Care Transitions
FQHC & Tribal Health Collaboration
Value-Based Care & Population Health