Appeals Clinical Reviewer Resume Example Landmark Health

APPEALS CLINICAL REVIEWER

Professional Summary

Proven ability to serve as knowledgeable, highly skilled nursing resource to providers, patients, and administrative teams within demanding and dynamic environments. Reliably develop and implement nursing care plans with a focus on patient communication, advocacy, and wellness. Committed to maintaining highest levels of accuracy, quality, and professional integrity while complying with all standards and regulations. Strong collaborator and team contributor readily managing priorities and working diligently to achieve common goals. Special expertise in women's health including labor and delivery and pre- and post-natal care.

Skills

Clinical Care & Discharge Planning
Education, Advocacy, & Support
Cross-Team & -Department Coordination
Insurance & Referral Documentation
Issue Resolution & Problem Solving
Information Management | HIPAA

MS Office Suite, Windows OS, Meditech, EHR, Intergy, Citrix, EMR
Problem Solving
Documentation
Case Management
Chronic disease management
Preventative health

Work History

Appeals Clinical Reviewer, 12/2019 to Current
Landmark Health – Randolph , NY

Broad knowledge of company policies and procedures.
Have in-depth knowledge of health plan rules, compliance standards and eviCore guidelines that are used to make Clinical decisions.
Work with minimalsupervision, but use resources as needed to ensure appropriate clinical decisions.
Possess skills to review clinical information submitted on all post decision cases and obtain all pertinent information to make decision.
Document information obtained in case and approve if appropriate.
Cases that cannot be approved are thoroughly and accurately documented, along with criteria used and then forwarded to appropriate Physician for final review.

Transition of Care Coordinator, 10/2018 to 12/2019
Job Corps – San Jose , CA

Serve as key member of Transition of Care program following up with insurance members after hospital discharge.
Calling out to members to provide medication reconciliation, assessing signs and symptoms related to members' health.
Providing disease specific education to help prevent avoidable hospital readmissions.
Acting as liaison between insurance companies and members.
Referring members back to insurance plan for continued case management if needed.

Registered Nurse, 07/2013 to 10/2018
Job Corps – Ottumwa , IA

Within established specialty clinic, serve as key member of clinical staff promoting women's health and wellbeing through preventative care and supportive treatment.
Handle pre-appointment matters, reviewing charts, ordering laboratory tests, and assessing need for required procedures.
Prepare rooms, direct patients, and collect histories and vital signs.
Assist physician with examinations and procedures, administer medications and injections, and provide follow-up instructions.
Manage post-appointment tasks to include maintaining patient records database, preparing documentation for insurance claims, submitting referrals, and cleaning exam rooms.
Return patient phone calls, prioritizing response base on assessed urgency of need and consulting with clinical providers on patient cases, treatments, and drug therapies.
Authorize medication refills.
Demonstrated ability to develop plans of care appropriate to established guidelines and in coordination with physicians.
Demonstrate adaptability by stepping up to provide direct obstetric care to meet operational needs during physician attendance on deliveries.
Serve as trusted, well-informed resource to patients and family members while providing education on nutrition, fitness, and self-care.

Registered Nurse, 01/2012 to 07/2013
Maury Regional Medical Center, Harton Regional Medical Center – City , STATE

In consecutive positions within Labor & Delivery Department of high-volume medical centers, provided direct care to up to four women and their infants throughout labor, delivery, and postpartum periods.
Triaged patients to assess dilation, monitored vital signs, and performed fetal assessment.
Educated patient on options for pain management; liaised with anesthesiologist for administration of epidurals.
Tracked progress, and communicated patient status to attending physician.
Prepared materials/equipment for labor and delivery.
Assisted with vaginal deliveries; assisted physicians and other providers and managed patient care during cesarean deliveries.
Followed postpartum care plans, performing routine checks and administering medications and injections.
Provided education on breastfeeding.
Key Contributions: •Quickly established rapport with patients and support persons while offering support, education, advocacy, and comfort; effectively managed expectations during high-stress situations.
Promoted positive and individualized decision making throughout labor and delivery process while meeting needs of women of diverse ages, backgrounds, and cultures.
Advised on relaxation techniques to improve patient breathing and minimize stress on mother and baby.

Education

Associate of Science: Nursing, 12/2010
Columbia State Community College - City, State

Associate of Applied Science: Nursing, 12/2010
Columbia State Community College - City

Resume Overview

School Attended

Columbia State Community College

Job Titles Held:

Appeals Clinical Reviewer
Transition of Care Coordinator
Registered Nurse

Degrees

Associate of Science : Nursing , 12/2010
Associate of Applied Science : Nursing , 12/2010

Appeals Clinical Reviewer Resume Example

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