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RN, Clinical Appeals Nurse Resume Example

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JamekaMcCombs, RN
Summary

I have over 20 years of experience delivering high-quality care to patients in multiple roles and environments. I have worked as a STNA, LPN, and currently as a RN.

Skills
  • Administration of Medications
  • Antibiotic Therapy
  • Bladder Irrigation
  • Blood Glucose Testing Devices
  • Care of Gastrostomy Tube
  • Catheter Care
  • Catheterization
  • Central Line Dressing change
  • Critical Thinking
  • Data Management
  • Documentation
  • Dressing Application
  • Dressing Change
  • Electronic Health Records
  • Empathy
  • Family Education
  • Geriatric Care
  • Healthcare Software/Microsoft Office
  • Injections
  • IV Therapy
  • Maintaining Patient Charts
  • Monitoring Vital Signs
  • Observation
  • Pain Management
  • Patience
  • Patient Assessment
  • Patient Education
  • Patient Evaluation
  • Patient Monitoring
  • Patient Care
  • Physical Assessments
  • Record Keeping
  • Suctioning of the Tracheotomy Tube
  • Tracheotomy Care
  • Venipuncture
Experience
RN, Clinical Appeals Nurse
City, StateCompany Name/Mar 2018 to Current
  • Responsible for the completion of clinical appeals of multiple states
  • Review and complete all provider and member clinical appeals within required timeframes
  • Review all information necessary to prepare External reviews
  • Communicate with state agencies and internal departments to prepare for External Reviews
  • Attend assigned External reviews and complete all required compliances
  • Complete required compliances for External review decisions
  • Apply CareSource Medical Policies and MCG guidelines when processing clinical appeals
  • Issue notification letters to providers and members
  • Issue administrative denials appropriately
  • Refer denials based on medical necessity to medical director
  • Maintain hardcopy documentation, Facets/Guiding Care/CCA documentation and appeals database documentation at 90-95% accuracy rates
  • Conduct monthly, quarterly, and ad hoc appeals reporting
  • Collaborate with the Quality Improvement and Clinical Operations Team Lead to prepare all requests for Independent External Reviews
  • Ensure compliance with regulatory and accrediting requirements
  • Perform any other job-related instructions, as requested
Registered Nurse, PAT
City, StateCompany Name/Jan 2019 to May 2019
  • Overseeing intake
  • Perform an initial physical assessment and interview the patient to obtain their medical history
  • Obtain any tests the surgeon has ordered, such as an EKG, and draw blood for lab work
  • Help patients understand the process, answer any questions they might have, and discuss their post-surgical care plan with them
Registered Nurse
City, StateCompany Name/Aug 2018 to Jun 2020
  • Assess, plan, implement, evaluate, and provide nursing care to assigned patients, utilizing the nursing process to facilitate the patient's progression toward optimal health
  • Assessed needs of patients in basic and complex situations, identified potential or actual needs, and communicates changes in patient status, needs or condition to the supervisor and physician when applicable.
  • Documents the assessments
  • Plans the care of patients and their families in response to identified needs, throughout the continuum of care, in collaboration with the transdisciplinary team
  • Documents the plan and revisions
  • Implements the plan of care by providing nursing interventions directly and/or appropriately delegating care to others, demonstrating competent and proficient nursing practice.
  • Responds appropriately and assists others in responding to emergencies in a calm and effective manner
  • Initiates and coordinates the evaluation of care provided and documents the patient's response to care provided by nursing and other members of the transdisciplinary team
  • Facilitates the identification and resolution of patient's admission, transfer and discharge needs throughout the course of care in collaboration with the transdisciplinary team
  • Identifies individual learning needs of patients and families and provides education in a manner that meets their special needs
  • Communicates with the Charge Nurse or Nursing Supervisor on changing patient needs or acuity for appropriate staffing
  • Facilitates the admission and transfer of patients including appropriate patient placement
RN Case Manager
City, StateCompany Name/May 2017 to Jan 2018
  • Use of keen assessment skills to recognize pain and symptoms and collaborates with the hospice physician to keep the patient comfortable and symptom-free
  • Educated families and other caregivers on recognizing symptoms and providing safe and competent care for the patient
  • Offered emotional and practical support for both the patient and their family/caregivers
  • Educated patients and families on the signs, symptoms and expectations of the dying process
  • Supervision of care provided by Home Health Aides (HHA) and Licensed Practical Nurses (LPN's)
  • IV Push Meds, Blood draws, Central lines, Catheterizations, Dressing changes, and report/document daily experiences with symptom management
Registered Nurse (RN) /LPN
City, StateCompany Name/Aug 2015 to Feb 2018
  • Demonstrated caring and empathy on home visits
  • Complete full assessments
  • Obtain orders as necessary for patient
  • Measure and administer medications as prescribed
  • Provide wound care, as needed
  • Provide catheter care
  • Provider tracheostomy and other stoma care
  • Ensured bedding is clean
  • Track and order supplies
  • Venipuncture as ordered
Registered Nurse
City, StateCompany Name/Nov 2015 to Current
  • Provide and contribute to assessment of client health status
  • Observe, report and record client data
  • Recognize and report changes in client's conditions
  • Assist in identification of health care problems and in formulating client needs
  • Contribute to setting realistic short-and long-term goals for assigned clients
LPN, Licensed Practical Nurse
City, StateCompany Name/Jun 2011 to Mar 2017
  • Provide high quality nursing care for patients, with responsibility for: Oxygen Therapy; Tracheotomy Care; Vital Signs; Wound Care; Nasopharyngeal and Oral Suctioning; Application of Dressings and Insertion of Catheters.
  • Follow up with timely, accurate, charting procedures
  • Verify prior shift information
  • Conduct initial assessment of patients admissions
  • Assist with discharge planning
  • Report changes in patient's conditions routinely and when requiring immediate attention
  • Collect specimens from patients for laboratory testing
  • Monitor, evaluate and record food and liquid intake/output levels
  • Orientate new personnel in areas of patient care, medical practices and procedures
  • Operate equipment and assistive devices to safely transfer patients
  • Dispense of medications
Education and Training
Associate of Science: NursingGalen College of Nursing2017City
Diploma-Licensed Practical Nurse: NursingMiami Valley Career Technology CenterDec 2007City
Additional Information
  • Nursing Licenses RN: OH, WV, IN and KY
Certifications
  • Basic Life Support (BLS) Certification
  • Advanced Cardiovascular Life Support (ACLS)
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Resume Overview

School Attended

  • Galen College of Nursing
  • Miami Valley Career Technology Center

Job Titles Held:

  • RN, Clinical Appeals Nurse
  • Registered Nurse, PAT
  • Registered Nurse
  • RN Case Manager
  • Registered Nurse (RN) /LPN
  • LPN, Licensed Practical Nurse

Degrees

  • Associate of Science : Nursing
    Diploma-Licensed Practical Nurse : Nursing

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