Highly skilled Nursing Professional with qualifications in Clinical
Nursing, Case Management Utilization Review, and Discharge Planning
Extensive Case Management,
Utilization Review, and Discharge Planning experience.
Volunteered to test,
rollout, train colleagues on claims/clinical software.
Served in mentoring new
staff in clinical resources, clinical review policies and procedures.
Experience with clinical
documentation, medical record audits and complaint reviews.
Self-directed with excellent analytical and communication skills.
Experience in managed care, coding concepts , CMS guidelines, DRGs, HIPPA, and JCAHO standards .
Experience in Interqual and Milliman criteria guidelines.
Consistently achieved above average QA/audit scores.
CignaDecember 2014 to CurrentInpatient Case Manager - Utilization Review Hartford, CT
Inpatient Case Management
United Healthcare/ WellMedJanuary 2014 to December 2014Transition Case Manager - Team Lead Dallas, Tx
Responsible for the case management activities across the continuum of
care including utilization management, inpatient care management
and transition of care for Medicare members.
Performed prior authorization
reviews, retro reviews, claims denials/appeals, and clinical reviews of
appropriateness of inpatient and outpatient services by following Interqual
medical guidelines and benefit determination.
Serve as an advocate for
members and their families and provide education on their disease process
and helping to identify community resources.
Participate in interdisciplinary conferences and Patient Care
Coordination Meetings to review clinical assessments and transition
discharge care plans.
AetnaSeptember 2004 to December 2013Onsite Case Manager - Utilization Review Dallas, TX
Performed all aspects of
Case Management and Discharge Planning at onsite facilities and as a
telecommuter for Commercial and Medicare members.
Utilization Reviews on inpatient admissions to assure the appropriate
level of care based on Milliman Care guidelines.
Responsible for the coordination
of discharge plan and care with physicians, staff, and facilities.
levels of care when requested care is not covered, identified
Managed health care
resources necessary and appropriate for achievement of desired outcomes.
AmerigroupAugust 2002 to September 2004OB Case Manager - Utilization Review /Quality Review Nurse Arlington, TX
Case managed High Risk
Maternity members to identify, screen, track, monitor and coordinate the care
of patients with multiple co-morbidities and/or psychosocial needs and develop
a nursing plan of care.
clinical review of inpatient admissions for appropriate level of care based on Interqual
criteria, and the coordination of alternative levels of care for members.
health care resources necessary and appropriate for achievement of desired outcomes.
Performed medical record audits, complaint reviews, investigation and tracking. Extracted data from systems and records and conducted quantitative and qualitative analysis of data for reporting. Performed data collection for HEDIS project. Participated in special projects.
Education and Training
BSN in progress.
Brookhaven/ El Centro College - Dallas, TX
Associate of Applied Arts and Science: Nursing Degree