Jessica Claire
Montgomery Street, San Francisco, CA 94105 (555) 432-1000,
Registered Nurse with twenty-three years of proven expertise in acute and chronic care, staff development, and family advocacy. Clinical Director dedicated to disease prevention with a track record of managing personnel, finances, company operations and admissions while providing the highest quality health care. Resourceful in completing projects and managing competing priorities. Strong leadership and decision maker who understands the importance of compassion and patience.
Core Competencies
  • In-Depth Geriatric treatment knowledge
  • Wound cleaning/care expertise
  • Medical clinical procedures comprehension
  • Skilled cardiac care nurse
  • IV drug therapy management
  • In-depth knowledge of disease management programs
  • Effectively influences others
  • Resourceful in completing projects and managing competing priorities in timely manner
07/2016 to 04/2017 Home Health RN Case Manager/Quality Assurance and Utilization Manager Chris 180 | Lawrenceville, GA,
  • Provided case management for clients by developing care plans, consulting with other health care providers such as physicians, therapist, Home Health Aides, and Social Workers, referring clients to other.
  • Reviewing and documenting patients' information and the type of medical treatment provided.
  • Assessing and ensuring the agency is following medical rules and regulations and providing optimum care to patients,Working closely with the medical staff towards improving health and aiding recovery of patients.
  • Examining medical reports and identifying gaps in the provided treatment.
  • Performed independent health assessments of individuals and families by evaluating their physical, mental, social and environmental health status; and providing nursing intervention based on assessment of need.
  • Conducted screening, diagnostic treatment and rehabilitative and supportive services as the senior nurse on a primary health care team.
  • Delivered high-quality and compassionate treatment to indigent and low-income patient community.
  • Actively participated in unit-based Quality Assurance Program.
  • Performed all tasks with a patient-centered focus while seeking opportunities for improvement of processes and treatments.
  • Managed caseload of 45 clients, providing education, treatments, IV therapy, phlebotomy, wound care and other nursing clinical procedures as ordered by physician.
10/2011 to 05/2016 RN Quality Management/Clinical Adviser/HEDIS Reviewer Humana | City, STATE,
  • Identified and educated providers and staff on missing elements in chart documentation. Provided education in regards to the Provider Opportunity Reports and Gaps in Care Lists, contributing feedback on HEDIS scores-to-date and opportunities to improve overall HEDIS rates.
  • Reviewed and performed quality checks to prepare medical records for the MRRV process.
  • Coordinated retrieval of medical records with provider offices.
  • Created and developed HEDIS Tip Sheets for physician practices and hospitals.
  • Served as a resource and subject matter expert to providers, provider staff, plan partners, and other departments on HEDIS specifications, coding, documentation and best practices.
  • Flourish and maintain trusting relationships with providers allowing for effective collaboration with health plan in reviewing actual medical care and trends in case management.
  • Developed and maintained quality care systems and standards, including but not limited to, creating and improving medical protocols/guidelines.
  • Assisted in development and promotion of new or revised physician and/or physician office practices/processes in order to deliver optimal, cost efficient patient care services as well as obtain highest Star Quality Measure rating goals set forth.
  • Aided in development of user friendly, specialized provider group reports and utilize for assessing strengths and weaknesses to create an action plan based on opportunities of growth recognized.
  • Identified variations in evidence-based medical practice and sub-standard performance and recommended opportunities for improvement within Provider clinics with improvement of Diabetes outcomes in a provider group by 24% 2013.
  • Initiate member outreach and survey support, compile information and prepare reports for management, utilize findings and trends to improve efficiency as well as customer satisfaction.
  • Maintain HIPPA regulations for consumer privacy and complete tasks in a timely manner, ensure compliance with NCQA, federal, state and other regulatory agency standards.
  • 96% accuracy on medical record review and abstraction.
  • Designed quality activities, facilitated teamwork and implemented project plans to elevate the organization Health Quality measurements.
  • Provided reports of quality activities and outcomes to committees.
  • Monitored Quality Improvement Program compliance with regulatory and accrediting agencies.
  • Outreach to both members and Provider offices to promote compliance and educate on updates to CMS Star Quality Measure guidelines.
  • Actively assist in assuring the member is taking advantage of maximizing their health care benefit to encourage good health.
  • Identified members eligible for Humana Disease Management Clinical Programs and/or assistant programs to facilitate enrollment.
  • Kept provider informed and updated of Humana rewards programs, changes and related initiatives.
  • Organized, at times lead, and participate in provider and departmental progress meetings.
04/2006 to 10/2011 Performance Improvement Supervisor/Alternate Director of Nursing Chase Health Care, Inc | City, STATE,
  • Led, participated and collaborated with auditors in State Survey process.
  • Utilized medical resources to ensure high quality care and cost-effectiveness.
  • Initiated project for better gloving/gowning techniques, infection related complications declined by 13%.
  • Created annual goals, objectives and budget and made recommendations to reduce costs resulting in 28% reduction in overall cost for the years 2008 through 2010.
  • Directed the installation of improved work methods and procedures to achieve agency objectives.
  • Constructed programs and initiatives to determine trends in health care provided and determining priorities during the improvement phase.
  • Regularly evaluated employee performance, provided feedback and assisted, coached and disciplined staff as needed.
  • Jumped in to fill gaps for on call rotation when necessary.
  • Monitored infection control procedures to ensure agency-wide health and safety.
  • Set vision and developed agency staff performance improvement activities.
  • Analyzed agency activities and data to properly assess risk management and improve services.
  • Actively served on Utilization Review Committee by reviewing policies, patterns of providers and sanction processes.
  • Contributed to and participated in community education projects to foster widespread understanding of the prevention and treatment of illnesses.
  • Incorporated evidence-based care into practice environment to ensure high quality care for patients and their families and decreased hospitalization of Congestive Heart Failure Patients by 19% in years 2009 and 2010.
  • Routinely evaluated the overall patient care within the agency and diligently enforced high standards.
  • Established and maintained positive relationships with government regulators, residents, families, other area health care providers, physicians and community at large.
  • Diligently monitored the QA (Quality Assurance) program to improve performance and maintain high standards of care. Deficiency-free survey in 2010.
  • Evaluated nursing notes to confirm that they accurately and completely described care provided and patient responses.
  • Designed quality activities and implemented project plans to elevate the agency Health Quality measurements.
  • Risk Manager Designee accounts for 25% of daily responsibilities which included event investigation, clinical care review committee meetings, oversee care plans that are executed by nursing and therapy disciplines; monthly statistical QA reporting to meet state mandated requirement.
  • Fostered interdisciplinary relationships by negotiation and consensus building to attain goals for all disciplines.
  • Partnered with community agencies and organizations dedicated to building healthier communities.
  • Created and updated quality policies and procedures annually and as needed.
  • Conducted training, orientation and developmental activities for healthcare team, providing coaching and mentoring.
  • Reviewed OASIS assessments and treatment plans and develop and implement a Plan of Correction for identified deficiencies.
  • Served as a liaison between the patient/caregiver, physician, healthcare staff providers, and agency management team.
  • Representative and spokesperson for the Performance Improvement Program and an active member of the agency's Professional Advisory Committee.
01/2002 to 11/2005 Director Of Nursing Chase Health Care, Inc | City, STATE,
  • Supervised 39 healthcare employees and all services rendered to patients.
  • Led recruiting and hiring, managed employee review process and ensured compliance with state and federal regulations.
  • Maintained clinical records, compiled data in meaningful form, and prepared reports for community, federal and state level agencies.
  • Evaluated notes from all participating healthcare providers to confirm that they accurately and completely described care provided and patient responses.
  • Performed 42 ADR Reviews and Re-submissions to payer source resulting in 100% reversal and payments in years 2002, 2003 consequential no further ADR reviews required from CMS in years 2004, 2005.
  • Administered, directed and coordinated all activities of the agency.
  • Minimized staff turnover through appropriate selection via interviewing, recruiting, orientation, training, staff education and development improving annual retention rate from 85 percent to 24 percent. .
  • Revised policies and procedures, implemented and enforced in accordance with changes in local, state and federal laws and regulations resulting in Deficiency Free State Survey in years 2003 and 2004. 
  • Ongoing monitoring of Adverse Events and creating and implementing an Action Plan with alterations as needed based on assessment of outcomes.
  • Routinely evaluated the overall patient care within the agency and diligently enforced high standards.
  • Effectively served as an advisory resource by providing patient/family experience expertise.
  • Planned and organized staff development and orientation programs for all healthcare team staff.
  • Monitored infection control procedures to ensure agency-wide health and safety.
  • Conducted probationary and annual performance evaluations of all healthcare staff.
  • Kept abreast of advances in medicine, computerized diagnostic and treatment equipment, data processing technology, government regulations, health insurance changes and financing options.
  • Implemented Clinical Track Disease Management tools in nursing processes resulting in decrease in rehositalization of patients with COPD by 31% in years 2003 and 2004. 
  • Ongoing Utilization Management with decrease in cost of waste of supply stock by 18% in year 2007
Education and Training
Expected in Associates Degree | Registered Nurse Our Lady of the Lake College of Nursing, Baton Rouge, LA GPA:
  • Management: In depth knowledge of Case, Risk and Utilization Management and Quality Assurance Study. Superior knowledge of utilization review and third party payer criteria. Thorough understanding of regulatory agencies, statistical methodologies and process improvement. Exceptional familiarity with Medicare, Medicaid, OSHA, HCFA and state guidelines. OBQI/OBQM and Case Management.  Extensive organizational requirement managing experience.  Outstanding multitasking and prioritization skills.  Exceptional proficiency in risk analysis documentation.  Surpass ability with directing, and motivating healthcare teams that provide excellent and cost efficient patient care.
  • People skills: Strong leadership, professional and interpersonal skills, good communication skills with ability to persuade team members, advanced problem-solving, excel in problem conflict and resolution methods, well rounded critical thinking proficiency, take precedence in paying attention to detail.

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School Attended

  • Our Lady of the Lake College of Nursing

Job Titles Held:

  • Home Health RN Case Manager/Quality Assurance and Utilization Manager
  • RN Quality Management/Clinical Adviser/HEDIS Reviewer
  • Performance Improvement Supervisor/Alternate Director of Nursing
  • Director Of Nursing


  • Associates Degree

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