Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Toni Basaldu

Jacksonville,FL

Summary

Experienced leader and LPN with 20+ years experience in Managed Care/Utilization Management with a proven track record in staff leadership, creating a positive workplace culture, high-performing teams and quality improvement through effective training and mentoring while driving operational efficiency. Eager to bring a positive attitude, contribute to team success and commitment to continuous learning and growth.


Detailed oriented with strong problem-solving, analytical, communication, and teamwork skills with a proven ability to quickly adapt to new environments. Able to multitask and manage complex projects. Recognized for taking proactive approach to identifying and addressing issues, with focus on optimizing processes and supporting team and organizational objectives.


Overview

23
23
years of professional experience
1
1
Certification

Work History

Care Management Associate Manager

Aetna
11.2007 - 07.2024
  • Managed clinical and non-clinical staff reviewing pre-authorization (pre-service: inpatient, outpatient, DME, non-participating in-network requests) and concurrent (acute and post-acute) review requests along with managing the daily incoming and on-hand inventory and ensure timeliness is met.
  • Collaborated with internal and external constituents to ensure efficient processes and workflows are created and communicated.
  • Completed PTO/timesheets/schedules
  • Cross-trained existing employees to maximize team agility and performance.
  • Established performance goals for employees and provided feedback on methods for reaching those milestones.
  • Evaluated employee performance and conveyed positive and constructive feedback to staff
  • Maximized performance by monitoring daily activities, reports, audits and mentoring team members.
  • Conducted team meetings and 1:1's through Microsoft Teams
  • Resolved staff, provider and member conflicts, actively listening to concerns and finding appropriate middle ground solutions
  • Interviewed and hired employees.

Licensed Practical Nurse

Southlake Nursing and Rehab
11.2005 - 12.2007
  • Provided care for up to 35 patients per shift; including admissions, discharges, and medication administration
  • Offered immediate assistance in emergency and routine situations to evaluate needs and deliver care.
  • Used aseptic techniques to provide sterilized wound care and dressing applications.
  • Collaborated with interdisciplinary team of healthcare and social service providers to address patients' needs through effective intervention and care planning.
  • Documented accurate and complete patient information to address patient problems and expected outcomes.

Pre-Authorization Nurse (Promoted)

Aetna
01.2006 - 11.2007
  • Completed medical necessity reviews for pre-authorization (inpatient, outpatient, DME, Transition of Care and Non-participating provider requests) using Clinical Policy Bulletins (CPBs), Milliman Care Guidelines (MCG), NCD/LCDs and state/federal regulations
  • Communicated with providers, members and vendors to obtain clinical information for pre-authorization requests.
  • Utilized multiple systems and applications to complete reviews
  • Collaborated with leadership to devise initiatives for improving employee satisfaction, retention and morale.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Participated on workflow workgroups to devise/update written job aids
  • Implemented and hosted a training hour each week for education and questions
  • Created a team newsletter

Grievance Appeals Analyst

First Coast Service Options (Blue Cross/Blue Shield)
04.2001 - 03.2005
  • Analyzed and rendered determinations for Medicare non-complex appeals
  • Utilized department guidelines and review tools to conduct reviews

Education

Licensed Practical Nurse -

First Coast Technical Institute
St. Augustine, FL
06-2005

High School Diploma -

First Coast High School
Jacksonville, FL
1996

Skills

  • Medicare (CMS), Commercial, Individual health plans and State TAT/regulations
  • Pre-Authorization (including inpatient, outpatient, DME, Non-participating), Concurrent and Transition of Care medical necessity reviews
  • HIPAA compliance
  • MCG and Clinical Policy
  • Computer proficiency including MS Office (Teams, Office, Word, PowerPoint, Excel, One Note, Forms)
  • Quickbase experience
  • Verint phone technology
  • Inventory & Timeliness management
  • Current procedural terminology (CPT)/Medical terminology/ICD-10
  • Continuous process improvement

Certification

  • Licensed Practical Nurse (2005-Present)


Timeline

Care Management Associate Manager

Aetna
11.2007 - 07.2024

Pre-Authorization Nurse (Promoted)

Aetna
01.2006 - 11.2007

Licensed Practical Nurse

Southlake Nursing and Rehab
11.2005 - 12.2007

Grievance Appeals Analyst

First Coast Service Options (Blue Cross/Blue Shield)
04.2001 - 03.2005

Licensed Practical Nurse -

First Coast Technical Institute

High School Diploma -

First Coast High School

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