Dedicated and experienced Registered Nurse and Certified Case Manager licensed in ten states with strong clinical and people skills with over 20 years of experience and over 14 years experience in managed care environment.
Strong clinical judgment
Successfully directs staff meetings
Complex problem solving
Problem resolution capability
Vendor sourcing and negotiations
Chronic Care Management Coordinator05/2013 to Current Alegis Care – 1340 S Damen Ave Suite 400 Chicago, IL 60608
Effective counseling in health maintenance and disease management.
Processed monthly reports for department performance.
Liaised between patients and physicians to ensure patient comprehension of treatment plans.
Trained new staff on the CCM RN Role and Provider/RN Protocols.
Created and Performed monthly inventory and maintained medical supply counts.
Created and maintain CCM RN Training Manual.
Create and maintain relationship with Vendors in all markets of CCM and CCP Programs.
Customer Centricity Ambassador
Create and maintain workflows in CCM and CCP Programs
Decision Maker/Care Management Specialist10/2011 to 05/2013 Banker's Life and Casualty Insurance, Inc – Chicago, IL
Demonstrated customer forcused care by reviewing long term care claims for policy holder eligibility and provider eligibility, for benefits of home health, facility, hospice and respite care according to policy requirements.
Evaluate policy holders for cognitive impairment, functional incapacity and medical necessity of care in an objective manner to ensure financial and operational integrity.
Worked with claims examiners, claims assistants and customer serive to process all claims fairly, accurately and timely in accordance with all Federal and State laws and regulations.
RN Clinical Advisor - Humana Beginnings05/2003 to 07/2011 Humana Health Plan, Inc – Louisville, KY
Empowered pregnanct and postpartum women, with all different types of health conditions, in making the best health decisions via telephonic communications.
Ongoing patient education, encouragement, and referrals to appropriate resources, including internal disease management programs.
Guided members on knowing and accessing their benefits via the Humana.com website.
accurately documented calls in narrative and specialised documentation programs.
Successfully managed a caseload of 300-375 members.
Provided support, encouragement and sympathy with fetal loss.
Appropriately triaged and referred patient's back to their Primary Care/OB Physician when necessary for immediate care.
Monitored, via secured website, medically conplex newborns and empowered, guided and encouraged the infant's parents on an ongoing basis while the infant is in the NICU or in seeing other specialists as necesary.
Obtained, managed and maintained Registered Nurse licensures in eleven states.
Nurse Review Coordinator - Grievance and Appeals09/1999 to 05/2003 Humana Health Plans, Inc – Chicago, IL
Identify, investigate, research and resolve all issues identified in correspondence and telephone inquiries.
Research inlded contract language review and interpretation via employer and provider, member benefit interpretation, review of State Laws and Federal Regulations including CMS guidelines, review of system information, and obtaining and reviewing medical record documentation for contracted and non-contracted providers or other outside entities if appropriate.
Met all delfined time constraints as mandated by legislation, regulatory bodies and Humana bulletins when reviewing Denials of Serivces and Claims.
Assisted management and other internal departments in coodination or care or in solving multiple issue situations.
LDRP RN05/1998 to 08/1999 Holy Cross Hospital – Chicago, IL
Effectively responsible for the care of women and their families in various stages of labor and the birthing process.
Proficient in the care of high-risk pre-term labor patients.
empathetic care and support of women and their families in the event of fetal demise or miscarriage.
Charge Nurse responsibilities and duties on assigned shifts such as patient assignments, handling difficult situations and patient complaints.
Efficiently and effectively worked in all divisions within LDRP such as Triage; Labor and Delivery; Circulating in OR for OB related cases, Recovery Room RN for OB related cases; Postpartum care of patient, infant and family; and Newborn and Neonatal Intensive Care Unit.
Labor and Delivery RN01/1996 to 05/1998 Cumminity Hospital – Munster, IN
Effectively responsible for the care of women and their families in various stages of labr and the birthing process.
Proficient in the care of high-risk pre-term labor and high-risk labor patients.
Empathetic care and support of women and their families in the event of fetal demise or miscarriage.
Nursing SupervisorWomen's Wellness Center – Munster, IN
Developed and implemented a home health program of follow-up care for postpartum and post-operative patients; designed post-operative teaching sheets, adult and infant assessment sheets; proficient in home assessments of mother and infants.
Worked closely with a multi-physician office and staff.
Responsible for weekly schedules of Nurses and Medical Assistants and their assignments to each physicians' schedule of appointments; conducted procedural meetings; supported and assited Office manager with surgery scheduling, customer relations and telephone triage; and patient educational inforamtion.
LDRP RNSt. Margeret Mercy Health Care Centers – Hammond and Dyer, IN
Mastered cross-training to Mother-Baby Care; Newborn Nursery; Special Care Nursery; OB OR Circulating RN; OB PACU RN; OB Triage; High-Risk Pre-Natal Care and Labor and Delivery.
Cross-trained to Pediatrics and provided coverge as needed.
Provided Empathetic care of mother and family during and after a fetal demise or miscarriage.
BookkeeperHeikema Accounting – Hammond, IN
Responsible for bookkeeping, weekly payroll and payroll taxes, inventory control and general office duties.
Associate of Science: Nursing1994Purdue University -