Precertification Nurse (Prefer work at home)
** ****** ******, **********, ** 06786 Montie0327@ Comcast.net
DOB 3/27/1951 Cell (860) ***-****
Precertification Nurse Consultant 05/07-Present
• Support comprehensive coordination of medical services including making initial
coverage determinations, screening and referrals to Aetna Medical Services Programs.
• Make it possible for members to get the right health care treatment for their needs.
• Upon careful review of clinical documentations, authorize or deny such services as; inpatient stays, ambulatory surgery, home health care, DME, Chemotherapy, etc.
• Work directly with the Medical Director in making medical determinations for member services.
• Meet turn around times in all medical decisions in a fast paced environment.
Nurse Consultant-Temporary HEDIS Project
CONNECTICARE, INC. 11/95 – 11/2005
Nurse Coordinator Quality Improvement /Preventive Health
• Participated in the process of credentialing potential providers & participated in the
recredentialing process of already participating providers.
• Conduct pre-contractual site visits and review medical record keeping practices of
potential providers' and make recommendations according to ConnectiCare/NCQA
• Conduct medical record reviews at the time of recredentialing. Perform re-visits on those who
• did not meet the recredentialing standards.
• Perform site visits when necessary.
• Educated practitioners/providers regarding ConnectiCare, & NCQA standards to promote compliance and acceptance of current expectations & standards.
• Participates in yearly HEDIS audit data collection.
• Propose, designed & implemented projects to improve compliance.
• Analyze the results of interventions and develop new Quality Improvement Initiatives.
• Personally responsible for developing colorectal cancer awareness initiatives to better educate our members as to the importance screenings. Target group ages50 Plus. Wrote articles for our newsletters and our Internet web sight.
• Created and implemented ConnectiCare’s first “fall prevention” in the elderly initiative program.
• Maintain our Mammography/Cervical Cancer and Osteoporosis programs including monthly
mailings, education, etc.
Uncovered a major case of fraud while conducting field audits of a physician’s office. This discovery has escalated to involving the FBI, which resulted in a major savings to ConnectiCare.
Case Management- High Risk Pregnancy
• Temporarily assigned as Case Manager for high-risk pregnancies.
• Received an award for the outstanding & commendable role I fulfilled in managing high-risk pregnancies during my stay. I was offered this opportunity due to my extensive knowledge in the OB/GYN field.
MD HEALTH PLAN
HOSPITAL INTAKE COORDINATOR
• Responded to phone calls from provider’s offices using protocol and approved guidelines
and authorized specific identified services.
• Managed pre-determination process with the help of GMIS
• Obtained clinical information & member history to support medical necessity.
• Code authorizations with appropriate CPT & ICD-9 codes
AMBULATORY REVIEW FLOAT NURSE
• Analyze & adjudicate provider claims according to established protocol.
• Research & review provider appeals
• Responsible for telephone inquiries & requests
• Identify physical medicine cases requiring consultant review & confer with consultant.
PHYSICAL THERAPY/CHIROPRACTIC REVIEW NURSE
• Reviewed physical therapy & chiropractic referrals & continuation of care plans. Authorized number of visits according to diagnosis, office notes & medical necessity.
• Handled high volume of problem related phone calls related to PT/Chiropractic issues.
• Worked directly with the Medical Director in problem solving issues such as appeals & denials.
• Working knowledge of Outlook, Word, Windows, Amisys & GMIS
NEW BRITAIN OB/GYN (6 doctors) 6/87-9/ 94
• High volume telephone triage nurse.
• Consoled parents & teens on STD's (including HIV), birth control, pregnancy, etc.
• Scheduled all surgeries at area hospitals.
• Coordinate & call in medications to pharmacies & provide medication instructions.
• Assist in all office procedures such as endometrial biopsies, colposcopies, suture removals, etc.
BRADLEY MEMORIAL HOSPITAL 1985-1987
• Various bedside nursing duties as well as filling in for the ER when needed.
• Excellent communication oral & written skills
• Able to handle situations appropriately & calmly.
• Personally handle sensitive & confidential information.
• Embrace change & love to be challenged
• Always seek opportunities for self improvement
• Good time management skills and organizational skills
• Possess strong written, verbal and interpersonal skills
• Team player
• Good computer skills
• Member of the US Coast Guard Academy Auxiliary and work under the direction of (and have been cleared & approved by) Homeland Security. Have security clearances.
LPN - 1985 - Secretary of the class. Graduated with Academic Achievement Awards
in all academic & clinical areas.
REFERENCES: Available upon request
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