Years of professional case management experience
Treva Talbert
Detroit,US
Summary
Accomplished Nurse Case Manager specializing in Complex disease management with progressive career history in direct patient care, diverse patient populations, clinical knowledge and care coordination within fast-paced environments. Works effectively with excellent communication skills amongst all levels of healthcare providers, physicians and administrators to address patient needs. Knowledgeable with multiple EMR charting systems, InterQual & Milliman/MCG, medication administration, and pharmacy reconciliation. Skilled at multitasking and prioritizing client needs and daily assignments.
Overview
11
11
Work History
Registered Nurse Care Partner
Commonwealth Care Alliance Michigan
09.2023 - Current
- Developed and modified patient care plans and assisted interdisciplinary team in identifying client needs and goals to determine priorities of care.
- Supported extended services through communication among social workers, therapists, hospital staff, and clients.
- Educated patients and caregivers on healthcare plan process and available benefits.
- Evaluated healthcare needs and goals for treatment. Connecting clients to available resources and optimal providers for care.
- Maintains medical records confidentiality at all times through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
- Utilizes proper telephone etiquette and judicious use of other verbal and written communications, following policies, procedures and guidelines.
Clinical Care Manager
CVS Aetna Duals Premier Plan
10.2018 - 03.2023
- Completed outreach and health assessments telephonically and face to face engaging clients and maintaining working relationships.
- Regularly assessed individual barriers to optimal health outcomes such as socioeconomic factors or access limitations, working diligently to address these challenges through tailored interventions.
- Assisted in management of patient utilization of health care system and provided patient education relative to health care needs, use of community resources and benefits available to membership in managed care.
- Verified patient insurance eligibility and identified primary care physician, contacting office to obtain required information.
- Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
- Scheduled appointments and transportation for patients not requiring emergency services but needing examination from provider.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
RN Case Manager
Sinai Grace Hospital
11.2016 - 01.2018
- Monitored and recorded patient condition, vital signs, recovery progress and discharge plan of care.
- Review and audit patient charts for quality measures and identified potential gaps in documentation
- Clearly and thoroughly explained diagnoses, treatment options and procedures to patients and loved ones, checking in to verify understanding.
- Delivered emotional support to patients and families during challenging times.
- Coordinated patient transfers to other facilities.
- Documented accurate and complete patient information to address patient problems and expected outcomes..
- Established continuity of care by completing patient management plans and paperwork by deadlines.
- Coordinated patient referrals to specialty providers.
- Ordered medical and laboratory supplies and equipment.
- Maintained patient confidentiality and adhered to HIPAA regulations.
- Organized and detail-oriented with a strong work ethic.
- Applied effective time management techniques to meet tight deadlines.
- Maintained up-to-date knowledge of payer-specific guidelines to ensure accurate authorizations for medically necessary services.
- Conducted ongoing evaluations of patients with physicians toward established goals, adjusting discharge planning as needed for optimal results.
- Served as a trusted liaison between patients, healthcare providers, and insurance carriers to facilitate efficient care delivery processes.
- Reduced hospital readmissions through effective discharge planning and coordination of post-discharge care.
- Expedited claim resolution by effectively communicating clinical rationale for treatment recommendations to insurance reviewers.
- Performed admission reviews for medical necessity based upon InterQual or MCG specification.
- Optimized turnaround times for prior authorization requests, collaborating closely with physicians and clinical staff to expedite necessary treatments.
- Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
- Coordinated seamless transitions of care across multiple settings including acute care hospitals, rehabilitation facilities, and home care services.
Education
No Degree - Case Management Certification
Wayne County Community College District
Detroit, MI05.2013
Associate of Applied Science - Nursing
Wayne County Community College District
Detroit, MI06.2004
Skills
- Chronic Disease Management
- Motivational interviewing
- Clinical assessments & monitoring
- Transition of Care Coordination
- Acute and rehabilitative care
- NCQA regulations
- Basic Life Support (BLS) certification
- Utilization review
- Clinical assessment
- Home care management
- Discharge Planning
- Referral coordination
- Client & Family Education
- Microsoft Office/Excel
- Complex Problem-Solving
- Critical Thinking
- Patient Advocacy
- HIPAA Compliance
- InterQual
- MCG Milliman
Timeline
Registered Nurse Care Partner
Commonwealth Care Alliance Michigan
09.2023 - Current
Clinical Care Manager
CVS Aetna Duals Premier Plan
10.2018 - 03.2023
RN Case Manager
Sinai Grace Hospital
11.2016 - 01.2018
No Degree - Case Management Certification
Wayne County Community College District
Associate of Applied Science - Nursing
Wayne County Community College District
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