Utilization Management Case Manager
Resume:
Brentwood, TN *****
Wanda Pippin, RN / RHIA
Qualifications
Utilization Management
Disease Management
Dual Diagnosis/Addictions
Psychiatric Care
Home Healthcare
RHIA/Computer Literacy
Lifespan Care
Q.A NCQA Training
Healthcare Auditor
Profile
Clinical staff RN with proven success in Utilization Management and Disease Management. Served in management roles, supervising up to ten employees. Track record of producing desired outcomes.
Career Highlights
Analyzed the protocol and expressed a need for a screening tool. Result: Tool was added to protocol.
Offered eight and 12-hour shifts. Result: Increased nurse satisfaction.
Managed case loads with Utilization Management and Disease Management. Result: Positive outcomes.
Implemented quality improvements. Result: Increased performance and productivity.
Completed coding project with Utilization Management. Result: Obtained correct codes.
MHIM: Standing in a Master of Informatics/Information program. Received my Certificate in Informatics/Information Management,2023.
Experience
Elevance/Gainwell
RN BH Case Manager, RN Case Manager: MA Medicaid. (InterQual). 2022-2023.
Screens members using clinical judgement, and criteria to assess needs. Conducts assessments to identify NEEDS AND develops a care plan. Monitors and evaluates EFFECTIVENESS AND modifies a plan. Supports members access to quality and effective care. Gainwell-RN, CASE MANAGER-MA MEDICAID. USED INTERQUAL FOR MA MEDICAID UM. MA WALL.
Medcor: COVID-19 Telephonic RN /Point of Entry RN Case Manager, State of TN-PHNC-1
Utilized Medcor’s screening tool for screening employees for Covid-19. Contract. 2021
Regional One-Screens ED patients for admission criteria, utilizing Milliman, Cerner, and communicates results to MD’s and Bed Control. Resigned. State of TN: Compliant hotline. Resigned/retired with 15 + years of state service.
State of Tennessee: RN3, MEU Unit. 2011-2018
Supervised two Employees. Evaluated Medicaid cases for Incapacity. Appeal, DAC Cases. Psych, Medical, IQ. Valued Evaluation. No disciplinary in my folder. 15 years of state service. AWS. The work process evolved to the EHR. RIF, due to low caseload. Retired from the State of TN.
Williamson Medical Center: Used Interqual and Meditech for Utilization MGT. 2008-2010
CCU, NICU, Telemetry, Oncology, Orthopedics, Med-Surg. Medicare, Workers Compensation. OB, CPC. Raise.
State of Tennessee
2006-2008
Health Records Auditor, RN3
Audit records using specific audit tools. Monitors medical records for compliance with local, state, and federal requirements, including ACA standards. Plans of correction for the monthly state facility monitors as well as the yearly institutional audits. Assists the infection control, and the continuous quality improvement departments with gathering of information on inmates with chronic conditions. Q.A. Projects for evaluation of continued compliance with ACA standards. Monthly chronic care survey. Interim Infection Control RN, 2007. Participated in the annual inspection of a facility and received “Best Annual Inspection” in 10 years with an “Exceptional” evaluation.
Managed Access, State of Tennessee
2005
Medical Record Data Collection
Project based; responsible for medical record data collection and capturing ICD-9-CM codes. State: Quality Oversight. EPSDT audits. Approved reading material. Collaborated with MCO’s.
HMC: Wellpoint Blue Cross Blue Shield
2003 – 2004
Registered Nurse
RN on the Diabetes team. Serviced CAD, CHF, Asthma, COPD, Peds, Screen Depression, and Hypertension Project. Fully productive evaluation. Merit Raise. Co. Closed the Franklin, TN office.
VA Hospital
2002 – 2003
RHIA Outpatient Coder
Input E/M codes and ICD-9-CM codes. 3M coding. Generated billable versus non-billable visits. Fully successful evaluation.
First Health Corporation Incorporated
2000 – 2002
Registered Nurse
RN, RHIA, BCM-1. Utilization Management. Psych, Dual Diagnosis/Addictions. Responsible for telephone and paper record reviews for hospital stays (children through geriatrics). Input ICD-9-CM codes. Received 6.5 to 7.5 out of 9 on evaluations. Laid off. Consolidated and moved to VA.
Elk Valley Home Health
1999 – 2000
Registered Nurse
Diabetic teaching, wound care, assessments, histories, and discharges.
5116 Victoria Cove
Brentwood, TN 37027
ad5dsi@r.postjobfree.com
Wanda Pippin, RN / RHIA
Experience, Continued
Tennessee Christian Medical Center
1999
Registered Nurse
Served in addictions, dual diagnosis unit. Geriatric and adult partial treatment programs. Above standard evaluation.
Middle Tennessee Mental Health
1997 – 1999, 2003
Psychiatric Nurse
Served in acute treatment program and ETP Forensic Unit. Adults through geriatrics. Treatment Team. Supervised 5-10 employees. Superior evaluation.
First Hospital Corporation
1997
Psychiatric Registered Nurse
Served children through adults, prn. Hospital closed.
Education
RN B.S.N. Belmont University – Nashville, TN
B.S. Health Information Management / RHIA UTHCS - Memphis, TN, Certificate MHIM /Informatics/Information,2023.
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