Highly experienced and energetic RN with proven clinical expertise and skills in leadership. Committed to supporting the interdisciplinary team with case management, specifically utilization review, claims review, clinical appeals, as well as workers compensation. Adaptable and resilient with extensive knowledge of the insurance industry. Passionate about implementing processes to improve patient care.
Skills
Case Management
Working knowledge of Milliman
HIPAA Compliance
Insurance Knowledge
Patient Care
Medication Management
Quality Management
Patient Information Collection
Work History
Nurse Case Manager, 10/2017 to 08/2021 Arthur J Gallagher & Co. – Long Beach, CA,
Medical Management and Cost Containment through Drug Diversion.
Managed the Nurse Auditor and Vendor Compliance Program achieving 14% off billed charges.
Reviewed the Pharmacy Report weekly identifying drugs that had been filled for other than work comp related issues as well as reviewed the Opioid Report weekly to identify improper use of Opioids.
Worked with Adjusters in all MSIG offices to explain the Medical Components of all claims and help bring those claim to final conclusions.
Worked with the Property and Liability Department reviewing claims for legitimacy of claim, medical necessity of treatment resulting in savings of over $100,000 on one claim alone.
Opioid fills dropped from 1827 to 1437
40% of Opioids prescriptions stopped after one fill.
Nurse Case Manager, Workers Compensation, 05/2011 to 01/2016 Centene Corporation – Denver, NC,
Account: New Jersey School Board Association Insurance Group
● Carried a caseload of up to 65 cases on a daily basis
● Worked with Adjusters at NJSB to determine causality of injury and other coverage issues.
● Scheduled appointments for patients with specialist and monitored care for appropriateness and utilization.
● Worked with School Board contacts to keep them informed of patient’s progress and return to work dates.
● Participated in Case Review Conferences.
● Performed Field Visits when necessary.
Director, Medical Management, 05/1999 to 06/2010 Common Spirit – Scottsdale, AZ,
Accountable for all clinical activities of an Integrated Delivery System ensuring integration for effective and efficient care delivery to patients.
Developed and designed reports which displayed clinical outcomes as compared to national norms highlighting significant opportunities for improvement.
Led discussion with Clinical Management Committee driving process changes to improve clinical outcomes.
Targeted and improved Diabetes HgbA1c testing 15% in one year for the entire physician team.
Designed and implemented individual practitioner collaboration with medical record audits with a goal of finding opportunities for improvement in both process and outcomes.
Synthesized audit findings and consulted with physicians designing improvements in a collaborative style resulting in multiple callbacks for additional consulting for process and outcome improvement.
Constructed and populated quarterly scorecard benchmarking all primary care physicians in the IDS group.
Collaborated with Pharmaceutical companies arranged physician education courses, four to six times annually.
Increased attendance through utilizing attendee satisfaction surveys and capturing requested topics for education.
Developed education programs for the community to increase awareness of a variety of medical issues evidenced by participant surveys indicating knowledge gained, would refer others, and worth my time scores above 50%
Contributed to length of stay discussion through discussions with Utilization with Utilization Management Committee focusing on improvements in clinical pathways and actions within individual cases.
Identified cases that were denied that were appropriate for appeal. Obtained signed consent for Appeal from patients. Wrote and submitted appeal leading to a more than 75% turnover rate.
Director, Care Management , 12/1997 to 05/1999 Landmark Health – Richmond, VA,
Accountable for Concurrent Review, Case Management activities of 800,000 member health plan with the goal of reducing length of stay
Re-engineered Care Management Department, converting from a centralized model to a regional decentralized model including job design, career ladder, inter process, training plans and process review procedures
Interviewed and hired over 400 employees in a four-month period to fill 300 positions.
Redesigned processes and work flows to maximize efficiency and effectiveness, reduced pre-certification average hold time by 60 seconds, deployed concurrent review nurses to high utilizing facilities for on-site review, designed case management entry and exit criteria.
Results included reduction in employee turnover by 20%, days/1000 by 15%, and cases exiting case management by 20%.
Developed and taught Concurrent Review class for all newly hired Rn’s using InterQual and Milliman Criteria.
Clinical Manager, Senior Care Medical Management, 10/1996 to 12/1997 Prudential Healthcare – City, STATE,
Responsible for implementation of Senior Care product in the NJ market.
Responsible for hiring staff, including Patient Educator, Medical Social Worker and Health Risk Assessment Screener to support clinical outcomes, goals and objectives.
Developed and implemented Health Risk Assessment Screening for seniors including questionnaire and deployment process steps such as when to call, how many calls to place, leaving messages.
Participated in oriented Sales and Provider Relations staff regarding Senior Care product as well as State and Federal Regulations regarding Medicare products.
Director, Health Services, 04/1995 to 10/1996 Cigna – City, STATE,
Responsible for all Utilization, Case Management and Government Program Activities.
Implemented on-site concurrent review at 15 major hospitals in Manhattan, Brooklyn, Queens and Long Island in less than four months.
Improved telephone answering time and abandon rates by 15%
Revised workflows to ensure prompt response to request for services resulting in decrease from 30-45 days to 10 days.
Developed process to improve time handling Concerns, Complaints and Grievances.
Implemented periodic educational programs for staff to increase knowledge of medical issues
Director, Claims Management, 05/1991 to 09/1995 Medical Foundation Services, Miami, Florida – City, STATE,
Managed department of 15 employees responsible for review of medical claims generated by employees of our clients. Clients ranged from large to small self-insured to managed care organizations.
Interacted with physicians, clients, TPA’s and employees to explain rationale for review determinations of claims or request for services.
Conducted client presentations and assisted clients in revising/updating benefit plans.
Performed line item bill audits on request.
Education
Associate of Science: Nursing, Expected in 05/1973 State College of Florida - Manatee–Sarasota, FLorida, GPA:
Resumes, and other information uploaded or provided by the user, are considered User Content governed by our Terms & Conditions. As such, it is not owned by us, and it is the user who retains ownership over such content.
How this resume score could be improved?
Many factors go into creating a strong resume. Here are a few tweaks that could improve the score of this resume:
