Registered Nurse and Certified Case Manager with over 20 years of combined Case Management and Utilization Management experience.
Registered Nurse in Tennessee
Certified Case Manager
Facilitate optimal reimbursement through accurate certification and complete chart documentation. Conduct admission and continued stay reviews based on utilization review criteria. Refer and consult with the case manager and social worker to promote appropriate continued stay or discharge in the absence of definitive documentation and/or review criteria to support hospital stay. Experience with ICD 9 coding.
On Site utilization review for acute hospital confinements for adults and pediatric members. Monitored utilization for HMO and PPO products, Utilized Milliman Criteria as management guideline
Case Manager for catastrophic cases for a managed Medicaid population, Coordinated health education and resources for members, Monitored and evaluated cost effectiveness and outcomes,
Implemented and managed a statewide central intake process for home care referrals, Managed growth of a referral base by an increase of 600% over 2 year period, Managed work flow of 13 staff members.
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