Summary
Overview
Work History
Education
Skills
Certification
Additional Information
Timeline
Generic

Zvinashe Johnson 'Nash'

Phoenix,AZ

Summary

Registered Nurse (BSN) Registered Nurse (BSN) with 19+ years of nursing experience working in various medical disciplinaries settings such as, hospital acute care, acute rehabilitation, skilled nursing and managed care. Currently possesses a bachelor’s degree in nursing, with extensive experience in direct patient care, case management, utilization review and clinical content creation and management. Proven track record in collaborating with matrix partners and multidisciplinary teams to provide, effective and positive patient outcomes.

Overview

20
20
years of professional experience
1
1
Certification

Work History

Director, Clinical Content Guideline Manager

Cigna Healthcare
01.2021 - Current
  • Works with Medical Directors to research, create and transform clinical concepts into guidelines and care pathways for chronic care programs
  • Assists with end-to-end development of clinical guidelines for health care plans who provide reviews for radiology imaging
  • Point-person to ensure that guidelines are presented to and approved by the Medical Advisory Committee annually
  • Point-person to ensure that clinical guidelines and Medicare policy updates are disseminated and applied throughout matrix partners and other multidisciplinary teams
  • Conduct gap analysis of evidenced based clinical guidelines with health plan policies
  • Adhere to all compliance policies and ensuring all guideline changes are tracked and made available to the Medical Advisory Committee, including internal and external clients
  • Responsible for managing clinical guidelines in a secure system and protecting the integrity of all documents for all programs.

Utilization Review Inpatient Case Manager

Cigna healthcare
04.2015 - 10.2021
  • Reviewed and determined medical necessity for inpatient admissions and treatments and provided verbal and written authorizations and adverse determinations for Medicare and Commercial plans
  • Utilized medical resources such as Milliman Care Guideline to ensure care and cost effectiveness
  • Responsible for meeting hospital contract timelines in review of medical necessity approvals and or denials
  • Responsible for presenting any potential recommendations for denials to medical director, including coordinating MD peer to peer reviews as needed, this also includes sending out denial letters with approved denial language to healthcare providers and customers
  • Assisted in discharge planning process in coordination with inpatient hospital case managers and clinical liaisons, ensuring adequate and appropriate disposition and post discharge plans
  • Maintained ongoing compliance with state, federal laws, URAC standards and NCQA guidelines
  • Understood and utilize ICD 10 and CPT codes with all reviews
  • Participated in required continuing education trainings including monthly Grand Rounds and national training forums
  • Identified case management needs and engaged customers in case management programs that will enhance positive health outcomes.

Medicare Complex Case Manager

Cigna Healthcare
07.2009 - 04.2015
  • Assessed, planned implemented, coordinated and evaluated options and services to meet individual health needs
  • Provided telephonic support to patients and assisted with management and coordination of care post hospital discharge
  • Provided nursing education to new oncology patients post discharge from acute care settings and provided ongoing management of care with outpatient providers
  • Provided chemotherapy education to oncology patients and provided resources for patient assistance programs
  • Advocated for appropriate care and acted as a liaison for Medicare patients
  • Identified gaps in care, through document findings and determined benefit coverage as needed
  • Developed patient centric health management plans, which included short term and long-term objectives
  • Coordinated and facilitated necessary care based on individuals’ benefits
  • Utilized and coordinate community resources for all patients being followed under the case management program
  • Collaborated with patient’s medical providers, other case managers and matrix partners to ensure the best quality service delivery to patients
  • Instituted monitoring, progress tracking and continuous re-evaluation of patient centric plans and provided education as needed
  • Ensured that patients maintained progress through their treatment plans via weekly telephonic support.

Registered Nurse

Saint Luke's Hospital
06.2008 - 09.2008
  • Worked with a staff nurse team, coordinating and providing care to patients with complex respiratory diagnoses
  • Assessed, planed and implemented care plans created for each patient
  • Supervised care given to patients by other licensed staff and unlicensed nursing professionals
  • Acted as patient advocate assessing patient status and notifying physicians on all clinical changes.

Registered Nurse

Banner Good Samaritan Hospital
09.2006 - 04.2008
  • Worked as part of a multidisciplinary team, providing care to patients with complex various diagnoses
  • Assessed, planned and implemented care plans customized for each individual patient
  • Instrumental in the improvement of the customer service score on the medical surgical unit
  • Prepared equipment and assisted physicians during examinations and treatments
  • Worked as part of float pool, exercising my nursing skills on other specialty floors such as: Renal, Oncology, Telemetry and Orthopedics
  • Provided nursing education on the importance of medical provider follow up and medication adherence post discharge from acute care setting.

Registered Nurse

Kindred Hospital
05.2005 - 08.2006
  • Worked as part of a multidisciplinary rehabilitation team
  • Accurately obtained and documented patient history and assessed individual conditions and needs
  • Coordinated and provided direct care to patients with complex respiratory conditions and a variety of diagnoses.

Registered Nurse

Lawrence Memorial Hospital
03.2004 - 01.2005
  • Provided care to patients with multiple medical diagnoses
  • Coordinated services, treatments and consultations using Meditech computer system
  • Assessed and evaluated the care given to patients by other licensed and unlicensed professionals.

Education

Bachelor of Science - Nursing

EUCATION Grand Canyon University
2011

Associate degree - nursing

Middlesex Community College
2003

Skills

  • Case Management, Utilization Review, Nurse Education, Clinical Research, Clinical Content Development, Literature Review, Matrix Partner Collaboration, Discharge Planning, Medication Administration, Medication Safety, Reporting, Workflow Optimization, Clinical Guideline Management, Healthcare Compliance and Privacy

Certification

· Microsoft Word, Microsoft Excel, Power Point, Herreto Clinical Content Data Base, Smart Sheet, Share Point, MHK

Additional Information

  • Registered Nurse

Timeline

Director, Clinical Content Guideline Manager

Cigna Healthcare
01.2021 - Current

Utilization Review Inpatient Case Manager

Cigna healthcare
04.2015 - 10.2021

Medicare Complex Case Manager

Cigna Healthcare
07.2009 - 04.2015

Registered Nurse

Saint Luke's Hospital
06.2008 - 09.2008

Registered Nurse

Banner Good Samaritan Hospital
09.2006 - 04.2008

Registered Nurse

Kindred Hospital
05.2005 - 08.2006

Registered Nurse

Lawrence Memorial Hospital
03.2004 - 01.2005

Bachelor of Science - Nursing

EUCATION Grand Canyon University

Associate degree - nursing

Middlesex Community College

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Zvinashe Johnson 'Nash'