Chemberli D. Cline

**** ********** **

Stone Mountain, Georgia 30038

770-***-****

acbmqm@r.postjobfree.com

Summary

To acquire a position within your company that will allow me to utilize my Healthcare

Administration and nursing skills and with proven performance afford me a career with

growth opportunities.

Centene Corporation-Nursewise/Nurse Response Division

Outbound Services LPN

November 11, 2013-present

• Under the direction of a Registered Nurse perform health risk screenings; provide

scripted health education to callers; participate in other health-related telephonic

programs

• Identify actual or potential health or safety needs in callers and facilitates intervention for

prompt resolution

• Document all call-related transactions according to department policies and procedures

• Maintain standards of professional verbal and written communication

• Work effectively with coworkers to maintain and improve operations

• Comply with Federal and respective state’s laws regulating health management

• Participate in organizational process improvement and quality improvement activities

• Submit Medical information into multiple company databases

• Medical Triage

• Customer Service facilitator

Ashford University full-time student

August 3, 2012- August 5, 2013

Masters of Arts in Health Care Administration

Judge Group-Recruiting Agency

Temp Prior Authorization Coordinator for Coventry Healthcare in Atlanta

April 16, 2012-August 3, 2012

Assists with the orientation of providers to the Plan's authorization and review

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procedures and work closely with participating physicians to secure information necessary

for utilization management.

Implements and documents utilization management activities, which incorporate a

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thorough understanding of clinical knowledge and appropriateness of medical services

related to effective cost containment.

Assures the medical necessity and appropriateness of the delivery of healthcare

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resources provided to

members as per their benefit package, through medical review of inpatient and

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outpatient service

Requests, utilizing established criteria, Interqual, clinical judgment, and Medical

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Director Guidelines.

Actively participates in the negotiation and notification processes that result from

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the medical record

Reviews with the facilities. Prepares notification letters of denied and negotiated

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days within the

Established time frames.

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Offers safe, effective alternatives to the inpatient setting for those patients

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requiring interventions prior to their hospitalization. Actively negotiates transitional levels

of care when services requested do not meet acute care criteria.

Utilized established criteria to authorize hospital admissions, diagnostic testing

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and ambulatory care services

Assures that members are utilizing contracted providers requested services are

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covered benefits, medically necessary, appropriate and of the highest quality.

Provides oversight of non-clinical staff in the screening of both verbal and written

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service requests.

Serves as resource on clinical issues for non-clinical staff to ensure information

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provided to members and providers is current and accurate.

Provides accurate, comprehensive, and pertinent utilization data and information.

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Assists in the identification and reporting of potential quality improvement issues.

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Responsible for assuring reports are sent to Quality Improvement department.

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Total Therapeutic Management

Hedis Nurse Abstractor- February 16, 2012 –April 2, 2012

• Hedis Medical Research

• Chart Abstraction

• Chart Reviews

• Commercial Insurance Chart Reviews and Abstraction

• Medical information pursuit

•Data Entry

Emdeon/Chamberlin Edmonds

Precertifcation Nurse Specialist- Sept 6, 2011-February 2, 2012

Write medical cases on a daily basis to submit to Medicaid for retrospective

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payment on behalf of the patient and hospitals.

Retrieve medical information from patient’s charts to submit to Georgia Medial

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Care Foundation for approval of medical claims

Update medical decisions into Pace system daily

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Use Interqual to meet the criteria for patients medical care stay

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Send account reports to team lead weekly

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Correspond with referral coordinates with Medicaid to petition and advocate for

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approval of care on behalf of the Medicaid recipients and medical facilities.

Knowledge of Medicaid rules and regulations set by Department of Community

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Health of Georgia

Knowledge of rules, regulations and policies set by Georgia Medical Care

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Foundation

Patient and Healthcare Facility Advocate

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Alliant Healthcare/ GMCF

Nurse Reviewer-September 2006-Sept 2011

• Perform reviews of provider prior approval/precertification requests.

• Perform other non-prior approval reviews such as prepayment and validation reviews

• Use Interqual books and database to review precertification cases submitted by medical

providers to verify if patient’s stay meets standard for in patient or outpatient stay

• Document the rationale for all review decisions using appropriate criteria

• Evaluates initial clinical information and approve cases that meet criteria

• Refer cases that do not meet criteria and cannot be approved by nursing judgment to a

Referral Nurse Coordinator

• Provide customer service to providers calling via telephone

• Retrospective Reviews/Practioner Office Visit reviews

• Maintain confidentiality of review information and medical records in accordance with

HIPPA compliance

Oakhurst Medical Center Inc. – March 1999-May 2008

Lead LPN/Nurse Manager/Perinatal Case Manager

• Community Health Nurse

• Provided skilled nursing to clients in an ambulatory care setting

• Supervised a team of eight medical assistants and 1 LPN

• Triaged patients in office and via telephone daily

• Referral Coordination/patient prescription assistance coordination/JCAHO coordination

• Disease and Perinatal case management

• Disease management teaching

• Performed various back office duties, phlebotomy, IV therapy, immunizations, ekg and

medication administration

• Assist physicians with various procedures

• Wound care management

• Utilization Review

• Reviewed and audited Charts

• Worked as Family Practice, Pediatric and OB/GYN nurse daily

• Research with treatment of patients with high cholesterol

• Maintenance of vaccine, medications and flu vaccine log

• Coordination and supervision of health fairs throughout the DeKalb and Metropolitan

area

• Diabetic and nutrition teaching

• Patient Care Advocate

• Training of any new employees

Newton General Hospital- August 2003-June 2005

Staff LPN

• Provided skilled nursing care to patients in an acute care setting.

• Worked with adults and pediatric patients

• Performed skilled care to patients according to doctors orders

• Phlebotomy, medication administration, wound care, accuchecks and IV therapy

• Documented confidential and accurate information into data base

• Patient teaching

• MD order transcription

• Supported RN and Physicians whenever necessary

• Worked as Med/Surg nurse

• Chart reviews and audits

Education and Training

Dekalb Technical Institute

Clarkston, Georgia

Licensed Practical Nurse Diploma Hours

800 Theory Hours

800 Clinical hours

March 1995-1996

Ashford University

Clinton, Iowa

Bachelors of Arts Degree in Healthcare Administration

Nov 2008- August 15, 2011

Masters of Arts Degree in Healthcare Administration

Jan 17 2012- August 5 2013

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