Medical Management Nurse
Resume:
BARBARA L. JACKSON, MSN, BSN, RN, LNC
McDonough, GA 30253 678-***-****
*****@*****.***
__________________________ ____________________________________ ____________
Master’s prepared Registered Nurse with focus in Leadership and Management. Cumulative of twenty plus years
experience. Ten years clinical nursing in acute inpatient settings, thirteen years Managed Care-Payor
health plan experience. Two years in Consulting, graduate of Legal Nurse Consultant program. Strong oral and
written communication skills, excellent presentation skills (MS Visio, MS PowerPoint). Extensive managed care
payor system experience use of CCS, FACETS, McKesson, UNIX, Windows, Citrix, Kronos, IDX, and Care Radius.
SUMMARY OF EXPERIENCE
Coventry Healthcare of GA
Atlanta, GA
Manager Health Services 2011-present
Responsible for daily operations of the Utilization Management Prior Auth Department for a health plan. Direct Management of a Commercial HMO-PPO plan with a Medicare product (Advantra) with some dual Medicaid members.
• Responsible for 17 direct reports of Nurses and Call Center support staff
• Responsible for implementing new initiatives/rollouts
• Oversight of Precertification Dept. workflows and processes
• Assist with Claims and Coding adjustments and disputes
• Coding certification/knowledge of CPT/HCPCS and ICD-9 codes
• Serves as a resource and or educator to physician/provider medical groups
• Facilitation and coordination of care for members with escalated issues
• Responsible for meeting contractual turn-around and processing times
• Strong understanding and usage of InterQual Guidelines
• Responsible for team audits, data collection and reporting
• Assists with CMS reporting requirements, understands, implements, and complies with CMS regulations as well as URAC guidelines.
• Assists on Implementation project team of Care Radius Medical Management System
XL Health Corporation
Atlanta, GA
Utilization Mgmt. Program Manager 2009-2011
Responsible for daily operations of the Utilization Management Department for a PPO/SNPs Medicare Advantage plan with some dual Medicaid members.
• Responsible for 22 direct reports including precertification/concurrent review nurses and Call Center support staff
• Direct management of Review nurses and Call Center support staff responsible for services (including prior authorization, DME, home health, admissions to acute hospital, (LTACH) long term acute care facilities, acute rehab, (SNF) skilled nursing admissions, and referral management)
• Responsible for implementation and streamline of workflow processes
• Serves as a resource and or educator to physicians/provider medical groups
• Clinical review of targeted review services and procedures
• Facilitation and coordination of care for members with escalated issues
• Responsible for meeting bed days and ELOS targets
• Coding certification/knowledge of CPT/HCPCS and ICD-9 codes.
• Strong understanding and usage of Milliman Care guidelines
• Assisted with CMS reporting requirements, understands, implements, and complies with CMS regulations as well as NCQA guidelines.
• Assisted on Implementation project team of McKesson product for a Medical Management System
XL Health Corporation
Atlanta, GA
Utilization Management Supervisor (Promotion) 2008-2009
Responsible for the daily operations of a Utilization Management Team for a PPO/SNPs Medicare Advantage plan with some dual Medicaid members.
• Responsible for 16 direct reports including precertification/concurrent review nurses and Call Center support staff
• Direct management of Review nurses and Call Center support staff responsible for Home Health services
• Responsible for implementation and streamline of workflow processes
• Serves as a resource and or educator to physicians/provider medical groups
• Facilitation and coordination of care for members with escalated issues
• Assisted with CMS reporting requirements, understands, implements, and complies with CMS regulations as well as NCQA guidelines.
• Strong understanding and usage of Milliman care guidelines
Great West Healthcare 2005-2008
Atlanta, GA
Senior Nurse Care Manager
• Performed telephonic case reviews for national and regional accounts.
• Performed disease management, case management, clinical account management, care management strategy and implementation, care management analysis and reporting.
• Performed authorization of inpatient and outpatient services based on Milliman and Inter-Qual guidelines.
• Expert in use of computer applications inclusive of Microsoft, Internet-Explorer, Word, Excel, and company medical software.
• Assisted in preparation for (URAC) site visits
CONTRACT LEGAL-NURSING 2004-2005
Carlock Copeland, LLP
Atlanta, GA
LEGAL NURSE CONSULTANT
(Medical Malpractice)
Evaluate the complex and diverse medical issues involved in the procurement of medical information, both from discovery documents and review of medical records, preparation of detailed medical chronologies, the analysis of defense strategies, research of the medical literature for the purposes of attorney education as well as investigation into alternative causation, and significantly the identification of potential expert physicians/witnesses in all areas of medical specialties.
CONTRACT LEGAL-NURSING 2003-2004
Insley and Race, LLC
Atlanta, GA
LEGAL NURSE CONSULTANT
(Medical Malpractice)
Evaluate the complex and diverse medical issues involved in the procurement of medical information, both from discovery documents and review of medical records, preparation of detailed medical chronologies, the analysis of defense strategies, research of the medical literature for the purposes of attorney education as well as investigation into alternative causation, and significantly the identification of potential expert physicians/witnesses in all areas of medical specialties.
CONTRACT LEGAL-NURSING 2003
Hawkins and Parnell, LLP
Atlanta, GA
LEGAL NURSE CONSULTANT
(Asbestos Litigation)
Evaluate the complex and diverse medical issues involved in the procurement of medical information, both from discovery documents and review of medical records, preparation of detailed medical chronologies, the analysis of defense strategies, research of the medical literature for the purposes of attorney education as well as investigation into alternative causation, and significantly the identification of potential expert physicians/witnesses in all areas of medical specialties.
BlueCross BlueShield of Georgia 2000-2003
Atlanta, GA
SR. UTILIZATION MANAGEMENT NURSE
• Alternate onsite and telephonic case reviews for Medicare and commercial accounts.
• Clinical Account Management, Case Management.
• Authorization of inpatient and outpatient services based on Milliman and Inter-Qual guidelines.
• Clinical Coding and Claims review
• Expert use of computer applications inclusive of Microsoft, Internet-Explorer, Word, Excel, and Company medical software.
• Assist in preparation for (URAC) site visits
Unicare 1999-2000
Atlanta, GA
UTILIZATION MANAGEMENT NURSE
• Performed clinical and coding telephonic medical record reviews for Georgia State Merit account.
• Clinical Account Management, Pre-certification of outpatient procedures Case Management.
• Use of medical clinical criteria of Milliman and Inter-Qual guidelines.
• Expert use of computer applications inclusive of Microsoft, Internet-Explorer, Word, Excel, and Company medical software.
• Assist in preparation for (URAC) site visits
AGENCY TRAVEL NURSING: 1993-1998
Clinical Duties: Traveled from state to state working 13wk-1yr assignments in Pediatric nursing settings. Primary specialty in Pediatric Hematology-Oncology; also worked various other units including: Cardiac, Renal, Neurology, Rehab, Intermediate Step-Down, NICU, ICU and Burn Unit. Performed various clinical nursing duties; such as, Chemotherapy Administration, Blood Transfusions and other invasive procedures as needed.
STAFF NURSE, TRAVEL RN
MEDSTAFF, Newtown, PA
SCOTTISH RITE CHILDREN'S MEDICAL CENTER, Atlanta, GA
Nov 1995 -Oct 1998
Performed clinical nursing duties in various acute care settings; primarily Oncology Unit. Telephone advice-line nurse in a Pediatric setting. Performed clinical nursing functions, supervisory tasks of Charge Nurse, and training new employees as needed.
STAFF NURSE, TRAVEL RN
TRAVCORPS, Malden, MA
CHILDREN’S NATIONAL MEDICAL CENTER, Washington, DC
May 1995 - Nov 1995
STAFF NURSE, TRAVEL RN
FLYING NURSES, Dallas, TX
TULANE UNIVERSITY MEDICAL CENTER, New Orleans, LA
July 1994 - May 1995
DALLAS CHILDREN’S MEDICAL CENTER, Dallas, TX
April 1994-July 1994
SUNRISE CHILDREN’S MEDICAL CENTER, Las Vegas, NV
Oct 1993- April 1994
STAFF NURSE, R.N
SCOTTISH RITE CHILDREN'S MEDICAL CENTER, Atlanta, GA,
June 1991-Oct 1993
Performed clinical nursing functions, supervisory tasks of Charge Nurse, and training new employees as needed.
EDUCATION
DREXEL UNIVERSITY, Philadelphia, PA, MSN, 2008 – Nursing Leadership and Management
DREXEL UNIVERSITY, Philadelphia, PA, BSN, 2006 – Nursing
KAPLAN COLLEGE, Boca Raton, FL, Diploma, 2002 – Legal Nurse Consultant
GEORGIA PERIMETER COLLEGE, Clarkston, GA, ADN, 1991 – Nursing
CERTIFICATIONS
Registered Nurse, 1991
Legal Nurse Consultant, 2002
CPR
PROFESSIONAL AFFILIATIONS
American Association of Legal Nurse Consultants
American Nursing Association
Case Management Society of America
Pediatric Nursing Association
LICENSURE
Georgia R000000
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