Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Vicky M Hamilton

Rancho Cucamonga,USA

Summary

Detail oriented Licensed Vocational Nurse with 13 years of healthcare experience with Managed care, Medicare and Medi-Cal population. Appeals grievance process and denial letter writing for Livanta Submission.

Professional in healthcare management, skilled in optimizing patient care and resource utilization. Known for collaborative teamwork and achieving impactful results in dynamic environments. Strong capabilities in clinical assessment and compliance with regulatory standards.

Overview

24
24
years of professional experience
1
1
Certification

Work History

Utilization Management Nurse

Dignity Health Medical Network
02.2022
  • Discusses the medical necessity of continued stay daily with the attending physician or the Medical Director when the level of care appears to be inappropriate, or member does not meet criteria.
  • Reviews all transitional care unit and skilled nursing admissions for appropriateness of the admission and ongoing for continuing care criteria being met with MCG and InterQual guidelines.
  • Coordinates discharge plan with hospital and skilled nursing case managers for timely discharge or transfer to lower level of care.
  • Issue Notice of Medicare Non Coverage to all transitional care and senior skilled nursing members prior to discharge or at the exhaustion of benefits.
  • Participates actively in assigned Care Management Coordination Committee meetings.
  • Ensures the appropriate utilization of capitated and contracted specialist, providers, facilities, and vendors according to the region and risk. Full and Shared risk.
  • Developed and maintain relationships with both network and Out of Network hospital UM and ER staff.
  • Perform telephonic review of prior authorization request for pertinent care and setting, following guidelines and policies, and approve services of forward request to physician or Medical Director with recommendations and determinations.
  • Educate providers on utilization and medical management process.

Inpatient Case Manager Tertiary Facilities /Grievance Appeals Specialist

Optum United Health Care
12.2023 - Current
  • Coordinate in providing care that is safe, timely, effective and client centered.
  • Facilitate higher level of care transfer to COE with Medical Director
  • Assess and develop a plan of care with hospital case manager and outpatient case management services.
  • Monitors inpatient hospitalization using evidence-based guidelines such as MCG Care Guidelines.
  • Participate in specialized training to meet the needs and better serve our client population.
  • Adhere to PHI and HIPPA compliance protocols.
  • Maintained accurate documentation of all case management activities, ensuring compliance with regulatory standards.
  • Maintained individual files such as case notes, intake and discharge summaries and releases of information.
  • Streamlined case management processes for increased efficiency and improved patient experiences.
  • Demonstrated exceptional problem-solving skills when faced with unique or challenging cases, resulting in successful resolutions that satisfied all parties involved.
  • Assisted in policy development by providing expert insights based on experience handling complex grievances and appeals cases.
  • Implemented quality control measures that ensured accuracy in case documentation and reduced instances of rework or errors in processing claims.
  • Enhanced grievance appeals efficiency by streamlining processes and implementing best practices.
  • Created, composed and maintained appeal response templates.
  • Coordinated with senior specialist to compose appeal responses.
  • Prepared insurance claim forms or related documents and reviewed for completeness.
  • Checked documentation for accuracy and validity on updated systems.

Inpatient Case Manager for out of Network/Prior Authorizations Nurse

Prime Healthcare Systems
06.2021 - 01.2022
  • Perform daily or as clinically indicated telephonic clinical reviews for patients in the acute hospital setting and in accordance with CMS, DMHC and managed care requirements.
  • Evaluate and monitor patients for inappropriate admissions, appropriate level of care and length of stay Apply MCG, goal length of stay or other applicable evidence-based guidelines (i.e.: Milliman, MCG). Assist in maintaining hospital bed days within goals
  • Repatriate patients whenever possible if admitted to out of network facilities. Assist health plan repatriate out-of-area patients by providing Hospital Bed Board and Hospitalist phone numbers. Ensure that patients are followed by assigned/contracted Hospitalist and Specialist
  • Maintain communication with the medical director daily and collaborate peer to peer discussion for out of network patients.
  • Provide accurate and complete documentation with rationale used to approve request.
  • Case discussion with UM Director CMO and Medical director to review excessive cost, high utilizer cases prior to approve to establish medical necessity.
  • Perform retrospective reviews on inpatient and outpatient claims.
  • Participated and conduct monthly rounds on inpatient and outpatient claims and reimbursement.
  • Manages the provision of cost containment services by determining the medical necessity and appropriateness of setting and treatment, and channeling to network providers

Inpatient Case Manager

Prospect Medical System
07.2020 - 01.2021
  • Effectively manage patients onsite and telephonically during their hospitalization to ensure appropriate level of care is provided for the patient’s severity of illness.
  • Utilizes the appropriate test and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner
  • Communication effectively with staff and hospitalist to gather clinical information through verbal and written communication.
  • Interact with patient and hospitalist daily to evaluate plan of care. Update clinical information in the electronic medical management record system
  • Facilitate transfer to in-network care when appropriate
  • Anticipate and initiates discharge planning with in the first 24 hours of admission
  • Communicate directly with providers involved with the care of the member. including IPA or hospitalist group.
  • Actively participates in daily rounds with Medical Director to identify clinical cases not meeting medical criteria using CMS medical guidelines

Managed Care Liaison/ Inpatient Case Manager LVN

Dignity Health Medical Network
02.2020 - 07.2020
  • Medical rounding on hospitalized patients and performed concurrent review with InterQual Criteria. Complete assessments to determine unmet needs, develops transitional care plans, evaluates, and identifies knowledge gaps of disease process and determine treatment with assigned medical director.
  • Actively participates in daily care management rounds, interdisciplinary team meetings and encourages multi-discipline group discussions.
  • Educated patient and family about care coordination outpatient case management program.
  • Coordinates with hospital care management team to facilitate the patient’s individual needs.
  • Identifies and coordinated transition from LTAC, SNF and ARU into ambulatory care management program.
  • Communicates with primary care and specialist physicians, regularly to evaluate the status of each patient. Collaborate with other team members to recommend appropriate setting, level of care and post- acute care plan.
  • Educate patient and family and /or caregiver about their disease processes.
  • Provide quality effective care in a timely manner

Acute Inpatient LVN Case Manager

Regal Medical Group Corp
01.2018 - 02.2020
  • Managed patients with SNP, Shared Risk, Full Risk, Cal Medi-Connect and Medi-Medi CCS and Whole Child Model lines of business.
  • Managed patient in acute Tertiary setting during inpatient hospitalizations.
  • Directly work and attend medical rounds with RMG Medical Director and RMG hospitalist multiple times a day to ensure hospitalization and care needs are within a timely manner.
  • Under direction of RMG Medical Director facilitate transfer of patient requiring higher level of care to contracted DRG contracted hospitals.
  • Assesses and develops a plan of care in collaboration with the admitting, attending and consult physicians, and other healthcare practitioners.
  • Responsible for the safe discharge of patients with the necessary resources to ensure that care is provided without interruption along the continuum of care, which is whether in a skilled nursing facility, assisted living facility or in the home setting.
  • Follow up post discharge Hybrid Program call made 24 hours after discharge continue to follow up with patient14 days post discharge to determine any problems, issue or risk encountered in the transition, on the 14-day patient will be introduced to their Vital Care Outpatient Case Manager for continuity of care.
  • Identifies and addresses psychosocial needs of the patient, family, and facilities with consulting with health plan Social Worker and Patient Advocate Team
  • Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, InterQual, CMS, National Recognized American Academy of Specific Specialty.

Outpatient LVN Nurse Case Manager

Alta Med Medical Group Health Services Corp.
03.2017 - 01.2018
  • Develop a working relationship with the hospital case managers, health plan, clinics, and other governing entities.
  • Provide input on the development of quality care plan and implement a care plan under the guidance of the RN.
  • Assist in performing and documenting patient outreach telephone and or face-to-face to reduce the likelihood of readmissions and responsibilities including but not limited to: PCP appointments, ensure DME Home Health is ordered, and providing referrals for social barriers for referrals to social workers.
  • Responsible for the daily review and processing of referral authorizations in accordance with turnaround time (TAT) standards set by ICE/Health Plan requirements.
  • Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, InterQual, CMS, National Recognized American Academy of Specific Specialty.
  • Assists with composing medical director denials to meet language requirements set by ICE/Health Plan requirements.
  • Interacts and effectively communicate with members, their families and or designated member representatives to assess their needs and formulate nursing care plan and smart goals.
  • Work alongside RMD to transition high cost and tertiary members to in network specialties for continuity of care.

Licensed Vocational Nurse

Alta Med Medical Group Health Services Corp.
07.2014 - 03.2017
  • Evaluated and triaged incoming patients as appropriate and providing immediate attention to most urgent cases.
  • Assessed the quality of ambulatory care provided to patients.
  • Checked and recorded vital signs perform phlebotomy, therapeutic injections, and stabilization activities to ensure patient readiness for physician examination and discharge.
  • Provided case/disease management services to high-risk patients and families’ mental health, wound care, diabetes, and hypertension.
  • Educated patient and families on medical diagnosis, medication management and treatments
  • Ensured patient record updates within EHR/EMR with considerable documentation to presenting acute illness.
  • Coordinated and facilitate services with internal and external resources.
  • Developed and maintained expected standard of quality patient care within the scope of practice of a Licensed Vocational Nurse.

Partial Inclusion Adult Day Program

Easter Seals of Southern California
11.2013 - 07.2014
  • Under supervision of program director Coordinates the delivery of healthcare service with adults with developmental disabilities in accordance with Title 22 regulations
  • Held weekly in services for caregivers
  • Medication administration
  • Discuss follow up appointments with caregiver and program participants.
  • Meet with caregivers and healthcare provider to discuss program participants progress while at day program
  • Document and report follow up care with healthcare provider
  • Evaluates and update charts for restricted health care conditions care plan

Domestic and International Travel Nurse Rancho Los Amigos
06.2013 - 07.2014
  • To administer patient care to ensure safety and comfort provide all proper medication and treatment as they are needed from originating to destination facility
  • Provide client reports medical equipment and medication to receiving facility
  • Ensure, provided, and secure all pertinent documentation until arrived receiving healthcare provider
  • Collaborate with interdisciplinary team regarding client’s condition and treatment

Licensed Vocational Nurse

Rancho Los Amigos Rehabilitation Center
02.2010 - 07.2014
  • Rehabilitation and Medical Surgical care for clients with acute and non-acute post stroke neurological disorders.
  • Strict medication regimen.
  • Closely observer and report abnormal findings
  • Observe heart rate and blood pressure monitoring.
  • Blood glucose monitoring hypo/hyperglycemic.
  • Along with Dialysis nurse assist with the care of client receiving hemodialysis
  • Monitor diet oral and enteral nutrition.
  • Assisting with activities of daily living providing encouragement to promote levels of independence.
  • Monitor and schedule follow up appointment with medical home providers and outpatient therapy.
  • Coordinate with rehabilitation team ensuring feedback and communication.
  • Provide patient and family education to prepare for discharge.
  • Participate in team admission with lead R.N.

Licensed Vocational Nurse

Rancho Los Amigos Rehabilitation Center
02.2008 - 02.2010
  • Rehab for clients with various levels of acute and non-acute spinal cord injuries
  • Care of clients with tracheotomy and mechanical ventilation therapy
  • Medication administration all routes
  • Specimen collection
  • Intermittent Catheterization and insertion on indwelling catheters
  • Pressure ulcer and wound care management
  • Patient and family education
  • Notifying Covering Physician on clients change of condition

Community Support Companion

Institute of Applied Behavior Analysis
03.2005 - 09.2008
  • Assisted in the care implementation life skills for young adults with developmental disabilities.
  • Community integration program
  • Program updates for caregivers and families

Certified Home Health Aid

Spirit Home Health Agency
09.2001 - 03.2005
  • Assist client in the home with activities of daily living
  • Monitor client by observing physical and mental condition intake and output
  • Educate client and family members how to use assistive devices
  • Maintain safe and secure clean health environment by following asepsis by following home care policy and procedure
  • Record and document client information in the clients’ home binder and reporting all important information to supervising nurse

Education

Associate of Applied Science - LVN Program

St Francis Career College
Lynwood, CA
06-2009

Associate of Science - Nursing

Los Angeles Trade Tech College
06-2002

Skills

  • Patient confidentiality
  • Ethical practice
  • Clinical assessment
  • Quality improvement
  • Utilization review
  • Healthcare regulations
  • Care coordination
  • Policy adherence
  • Medical necessity evaluation
  • Continuing education
  • Documentation and reporting
  • Inpatient care
  • Discharge planning

Certification

  • State of California, Licensed Vocational Nurse
  • American Heart Association BLS for Health Care Provider
  • California State Intravenous Therapy &Blood Withdrawal Certification
  • Mental Health First Aid National Council for Behavioral Health
  • Director of Staff Development

Timeline

Inpatient Case Manager Tertiary Facilities /Grievance Appeals Specialist

Optum United Health Care
12.2023 - Current

Utilization Management Nurse

Dignity Health Medical Network
02.2022

Inpatient Case Manager for out of Network/Prior Authorizations Nurse

Prime Healthcare Systems
06.2021 - 01.2022

Inpatient Case Manager

Prospect Medical System
07.2020 - 01.2021

Managed Care Liaison/ Inpatient Case Manager LVN

Dignity Health Medical Network
02.2020 - 07.2020

Acute Inpatient LVN Case Manager

Regal Medical Group Corp
01.2018 - 02.2020

Outpatient LVN Nurse Case Manager

Alta Med Medical Group Health Services Corp.
03.2017 - 01.2018

Licensed Vocational Nurse

Alta Med Medical Group Health Services Corp.
07.2014 - 03.2017

Partial Inclusion Adult Day Program

Easter Seals of Southern California
11.2013 - 07.2014

Domestic and International Travel Nurse Rancho Los Amigos
06.2013 - 07.2014

Licensed Vocational Nurse

Rancho Los Amigos Rehabilitation Center
02.2010 - 07.2014

Licensed Vocational Nurse

Rancho Los Amigos Rehabilitation Center
02.2008 - 02.2010

Community Support Companion

Institute of Applied Behavior Analysis
03.2005 - 09.2008

Certified Home Health Aid

Spirit Home Health Agency
09.2001 - 03.2005

Associate of Applied Science - LVN Program

St Francis Career College

Associate of Science - Nursing

Los Angeles Trade Tech College

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