health first health plans claims department resume example with 10+ years of experience

Jessica Claire
Montgomery Street, San Francisco, CA 94105 609 Johnson Ave., 49204, Tulsa, OK
Home: (555) 432-1000 - Cell: - - : - -
Professional Background

Certified Occupational Health Nurse; accomplished, motivated, cross-functional nurse manager with responsibilities in patient care, ongoing case management, triage, environmental and safety disciplines. I possess a well-rounded knowledge of the Ohio’s Worker’s Compensation Law, OSHA 29 CFR 1910 for General Industry, OSHA 300 and 301 record keeping, and regulations, NIOSH spirometry and CAOHC hearing conservation standards. I have an excellent record of progressive achievement as an RN with 18 years in Occupational Health and 10 years management experience. I have worked with Fortune 500 companies such as General Motors Co. LLC, TRW Automotive, and Campbell Soup Co. LLC. Recently relocated to FLorida in pursuit of a home health care or long term care position to broaden my practice in other areas of interest.

Skill Highlights
  • Extensive pre-hospital trauma care
  • BLS
  • DOT drug testing
  • BAT
  • Wound care
  • Chronic disease management
  • Alzheimer's unit
  • NIOSH Spirometry
  • IV fluids
  • Vaccinations
  • Home Health
  • Regulatory Compliance

•Reduced time and cost within the medical department at Defiance for many processes by removing redundancy and manual tracking, aligned the Defiance Medical Department with Corporate Health Services’ policies and procedures

•Provided leadership and coordination of all medical durable goods and equipment for blanket purchases within all GM North American Operations by coordinating the needs of each site with corporate buyer and Health Services leadership

•First to implement OMI Pulmonary function testing systems and provided others a system to follow

•Developed daily case audit sheets reducing errors to less than 1%, a GM Defiance first

•Managed a task force eliminating errors in annual audiograms and received the first ever best practice for the department during the 2008 UAW/GM Joint Health and Safety Audit

•Achieved a 75% reduction in recordable injuries in the first year of program implementation for Campbell Soup LLC and TRW

•Developed an effective approach to reducing compensation costs of musculoskeletal related claims from $150,000 to $26,000 in a three month period by the application of Functional Capacity Evaluations, Functional Job Analysis, and the implementation of an onsite physical therapy program

•Created the POPP program (Post Offer Pre-Placement) which enabled employer to safely place new employees through ergonomic guidelines resulting in reduced injuries

Professional Experience
03/2015 to 07/2015
Health First Health Plans, Claims department Maple Leaf Foods Brandon, MB,

Reviewed high dollar claims for medical necessity. Ensured accurate and timely claims handling for members of the plan. Ensured Medicare compliance. Followed NCQA guidelines in claims handling.

04/2014 to 02/2015
Staff RN, Skilled Nursing Facility Genesis Healthcare, Bryan Center City, STATE,

Developed patient care plans, including assessments, evaluations, and nursing diagnoses.Assisted patients with multiple chronic diagnoses, including COPD and asthma.Supported patients with customized patient teaching tools.Delegated staff nurse duties.Ensured efficacy of treatments through monitoring of treatment regimens.Provided treatment within scope of practice as defined by state law.Coordinated with doctors and registered nurses to develop care plans for patients.Educated patients about their treatments.Instructed patients and family members on proper discharge care.Monitored patients with acute conditions.Maintained patient privacy and confidential patient information.Tested patients' blood glucose levels.Utilized strong assessment skills to determine necessary patient care.Provided quality nursing care in accordance with resident care policies and procedures.Measured urine specimens and delivered them to the laboratory.Worked as part of team to execute proper care of body mechanics and safety of patient.Provided primary resident care and assistance with daily living activities.

07/2006 to 01/2014
Medical Manager GM Company, LLC City, STATE,

Supervised medical personnel, determined work assignments and established procedures. Evaluated employees, determined training needs, and initiated corrective actions. Participated in the selection and hiring of new employees. Assisted in coordinating the development of Health Services training programs for program and regulatory compliance. Maintained common practices and procedures throughout the department. Assisted medical director in cost reduction. Directed the maintenance of all employee medical records, ensured HIPAA compliance. Directed the maintenance of equipment and supplies. Provided, in a timely manner, the required governmental and corporate reports for regulatory compliance. Assisted with the establishment and maintenance of facility wellness programs. Interfaced with health services stakeholders in a knowledgeable and effective manner.

07/2004 to 07/2006
Health and Safety Assistant TRW City, STATE,

Cross functional position with a heavy emphasis on safety, OSHA compliant training and occupational health.

Responsible for the reduction in incidence rate, severity rate and worker compensation costs in the state of Ohio by focusing on individual needs, injury treatment and management. Provided 24 hour nursing care; acute injury triage and care, with responsibilities for injury and illness management in addition to annual exams as required by OSHA and wellness programs. General program management to include safety promotion, safety observations, health clinic relations and communications, and inspections. Provided support to the environmental program management, ISO 14000.

Education and Training
Expected in 2007 to to
Bachelor of Science: Health Care Management
Franklin University - Columbus, OH

Graduated Summa Cum Laude

Expected in 1994 to to
Associate of Applied Science: Nursing
Northwest State Community College - Columbus, OH


American Nurses Association

American Board of Occupational Health Nurses

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Resume Overview

School Attended

  • Franklin University
  • Northwest State Community College

Job Titles Held:

  • Health First Health Plans, Claims department
  • Staff RN, Skilled Nursing Facility
  • Medical Manager
  • Health and Safety Assistant


  • Bachelor of Science
  • Associate of Applied Science

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