Twenty one years as Registered Nurse with in XYZ, with patients from to geriatrics. Skilled care of adult patientswith chronic and acute conditions. Effective clinical manager and precep looking for an opportunity withmanagement and training responsibilities.Energetic and motivational Nurse and leader dedicated to driving
top-quality patient care. Looking for a position in a top-notch facility with a commitment to innovativeprocesses.Loyal, collaborative Nurse with a steadfast commitment to quality care and preventative careadvocacy. Additional expertise includes management and staff supervision. Strong desire to focus on preventativecare and health education.
Pre-Certification Registered Nurse RN, 04/2014 to Current TUFTS HEALTH PLAN – Watertown, MA
Manage daily caseloads of requests of coverage defined as clinically complex within the Tufts HealthPlan Medical Necessity Guidelines
Provide Medicare clinical review for request that require prior authorization
Write pre-certifications/prior authorizations utilizing all patient information available (written and computerized) from doctors, hospitals, facilities, etc.
Use ICD-9 and CPT codes to document information correctly
Timely disposition of coverage determinations by adherence to established time frames, making sure to follow Medicare guidelines for urgent turnaround time
Write pre-certification appeals within 48 hours of document retrieval
Interface daily with the Tufts Health Plan Physician Reviewers on all cases that fail to meet criteria of coverage
Contribute to the development of Medical Necessity Guidelines by participating in both the Commercial Clinical Coverage Committee and Tufts Health Plan Medicare Preferred Clinical Coverage Committee
Registered Nurse (RN) - Case Manager, 07/2007 to 04/2014 MYSTIC VALLEY ELDER SERVICES – Malden, MA
Responsible for performing the duties required by both the Clinical Assessment and Eligibility (CAE) andComprehensive Screening and Service Model (CSSM) contract with Mass Health and duties required bythe MA State Home Care ProgramsReviewed referrals for each consumer determined to be in need of home care services and determinedprogram eligibility according to specific state and federal guidelinesConducted initial home visits for the purpose of assessment and development of a personal care plan.Identified client needs and coordinate, implement patients' care while continuously assessing the client'sneeds and upgrading the plan of care accordinglyPerformed assessment and/or care management interventions for the referred and identified populationincluding home & skilled nursing facility visits and risk assessmentsProvided choices, services, community resources and targeted health education to a diverse populationrelated to health care goals of clients, provided families/caregivers with resources and support neededProvided yearly reassessments as deemed appropriate by state guidelines and interdisciplinaryconferenceParticipated in weekly team & interdisciplinary meetings with case & education presentationsPeer reviews of client records Worked in close collaboration with social care mangers to provideintegrated care for at-risk clients and provided case consultation on an as-need basis for Care ManagersServed as consultant to Protective Service program on health-related issuesProvided regular on-site meetings and education at skilled nursing facilities to meet the requirements ofthe Comprehensive Service and Screening Model (CSSM) and the Long Term Care Options program forpossible discharges and ASAP service coordinationLong term care nursing home determinationsHospital & Nursing Home discharge meetingsProvided accurate and timely documentation of patient services to reflect plans of carePerformed community education including community teaching on disease self management programsWorked with homeless clients with MH applications, & housing applicationsMet monthly production requirements and quality assessment requirements.
Charge Registered Nurse RN, 12/1995 to 07/2007 JEANNE JUGAN RESIDENCE/LITTLE SISTERS OF THE POOR – Somerville, MA
Responsible for 26 skilled nursing unitAssessing, developing, implementing and evaluation of careEnd of life care, and pain managementLead multi-discipline team meetingsPreceptor and education to staff on quality improvements in careAssisted in development of pain management program, policy and procedure for fall and safetyMedicare documentationMedicare and PPS submissionsUtilization review of charts, determination of Medicare eligibilityCommunication with third party payer sourcesMedication and treatments, reporting pertinent information to M.D.
Charge Registered Nurse (RN), 12/1993 to 12/1995 NEW ENGLAND REHABILITATION HOSPITAL – Woburn, MA
Coordination of patient needsNursing shift schedulingPreceptor to new nursing staffWork assignment of staffMedication administration, IV therapy, treatments, and code cart teamPatient and staff teachingAssisting M.D.
Registered Nurse RN, 07/1993 to 12/1993 SOLDIER'S HOME – Chelsea, MA
See Above Duties.
Graduate Degree: St. Joseph College of Maine MSN - Standish
BACHELOR OF SCIENCE: NURSING, Emmanuel College - Boston, MAGPA GPA: GPA: 3.75 Sister Marie Barry Scholar for High Academic AchievementGPA - 3.75Sister Marie Barry Scholar for High Academic AchievementNURSING