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appeals and grievance rn sr resume example with 8+ years of experience

Jessica
Claire
resumesample@example.com
(555) 432-1000,
, , 100 Montgomery St. 10th Floor
:
Professional Summary

Grievance and Appeals Lead

- Ambitious and looking to lead with purpose, inspiration and innovation while promoting a new culture and winning attitude. I would like to bring my expertise and experience into a new role to assist in leading the appeals staff.

-I am a professionally trained Registered Nurse with high standards. I am culturally competent to care for a wide variety of members with diverse needs. I am a team player and have a strong work ethic. I work well in a fast paced and high-pressured environment. Prior to Nursing, I worked for Blue Cross/WellPoint from 1987 to 2003 in the ISG division for sixteen years. I multitasked as a claims processor, adjuster, customer service representative and lead in my unit. I then advanced to the Training Department for several years and then spent my last 10 years in systems as a business analyst. I left Blue Cross in 2003 to enter nursing school.

Skills
  • Critical Thinking
  • Attention to Detail
  • Microsoft Windows and Office
  • Active Listening
  • Collaborative Team Player
  • Creative Problem Solving
Education
Walden University Minneapolis, MN, Expected in 08/2015 ā€“ ā€“ BSN : Nursing - GPA :
  • Majored in Nursing
Los Angeles County College of Nursing and Allied Health Los Angeles, CA Expected in 2005 ā€“ ā€“ Associate of Science : - GPA :
Moorpark College Moorpark, CA Expected in 2003 ā€“ ā€“ Associate of Liberal Arts : - GPA :
Work History
Northeast Rehabilitation Hospital Network - Appeals and Grievance RN, Sr.
Windham, NH, 03/2016 - Current
  • Nurse Appeals and Grievances, Sr Responsible for investigating and processing the medical necessity of appeals and grievance requests from members and providers.
  • Duties include, but are not limited to:
  • Reviews prospective and concurrent inpatient, and retrospective medical records of denied services for medical necessity.
  • Analyze and review post service member complaints concerning quality of care.
  • Extrapolates and summarizes medical information for medical director, consultants and other external review.
  • Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
  • Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
  • Documents and logs appeal/grievance information on relevant tracking and mainframe systems.
  • Generate appropriate written correspondence to providers, and members.
  • Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
  • Work on projects affecting development, interpretation and implementation of medical policy or other managed care initiatives/wave projects.
Northeast Rehabilitation Hospital Network - Registered Nurse
Salem, NH, 12/2013 - 02/2015

RN Interventional Radiology, St. Johnā€™s Hospital, Camarillo and RadNet, Beverly Tower Imaging Center

  • Worked flexible hours; night, weekend, and holiday shifts.
  • Worked various locations around the hospital.
  • Flexible, team and goal oriented.
  • Worked with radiology team to prep patients and rooms for interventional procedures.
  • Prep medications for use by the Interventional Radiologist.
  • When necessary, moderate sedation and monitoring including post care.
  • Patient monitoring when transferred from one department to another, ex: ICU to radiology.
  • Update charts as appropriate.
  • Provided bedside reports to peers during transitions or shift changes.
  • Placed reminder calls to patients prior to procedures with pertinent instructions.
  • Placed follow up calls post procedure to ensure patients well-being and answer any questions or concerns.
  • Duties included; placing IV's for CT and MRI scans, administer sedation medications and monitoring, performing and processing I-stat's for creatinine testing and glucose testing.
Wellpath - Registered Nurse
Cleveland, OH, 07/2013 - 02/2015
  • Duties included; preparing the patient's for vascular procedures and charting documentation, assisting physicians as needed, assisting patient's with discharge.
  • I have also worked with several surgery centers as the pre/post op nurse, circulating and discharge nurse.
  • AIDS Healthcare Foundation: Telephone Triage, blood draws, injections, vital signs Planned Parenthood, Recovery, discharge and medication nurse.
American Red Cross - Supervisor, Registered Nurse
City, STATE, 02/2011 - 08/2012
  • Responsible for set up and break down of the blood drive.
  • Timely start of Blood Drive.
  • Safety of all staff and donors and staff followed policies and procedures.
  • Submission of daily and monthly blood drive reports.
  • Ensuring customer satisfaction.
  • Held daily briefings with staff prior to and following all blood drives.
  • Attended weekly conference calls with senior management and peers.
  • Prepared staff reviews annually.
  • Performed corrective action with staff as necessary.
  • Performed blood draw for donation.

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Resume Overview

School Attended

  • Walden University
  • Los Angeles County College of Nursing and Allied Health
  • Moorpark College

Job Titles Held:

  • Appeals and Grievance RN, Sr.
  • Registered Nurse
  • Registered Nurse
  • Supervisor, Registered Nurse

Degrees

  • BSN
  • Associate of Science
  • Associate of Liberal Arts

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