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Precertification Nurse (Prefer work at home)

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Country: United States
State: Connecticut
City: Terryville
ZIP: 06786
Salary: $55,000
Posted date: 12/10/2008   all resumes
Email: uqr4fd@r.postjobfree.com
Contact Info: **********@*******.***
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MONICA AIELLO____________________________________________________
** ****** ******, **********, ** 06786 Montie0327@ Comcast.net
DOB 3/27/1951 Cell (860) ***-****


EXPERIENCE: LPN


AETNA, INS.


Precertification Nurse Consultant 05/07-Present

DUTIES
• 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
01/2007-05/200


CONNECTICARE, INC. 11/95 – 11/2005

Nurse Coordinator Quality Improvement /Preventive Health
Credentialing/Recredentialing

DUTIES
• 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
standards.
• 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
94-11/95
HOSPITAL INTAKE COORDINATOR

DUTIES
• 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

DUTIES
• 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

DUTIES
• 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
OBSTETRICAL/GYNECOLOGY NURSE

DUTIES
• 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

MEDICAL/SURGICAL NURSE

DUTIES
• Various bedside nursing duties as well as filling in for the ER when needed.

PERSONAL QUALITIES
• 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.

EDUCATION
LPN - 1985 - Secretary of the class. Graduated with Academic Achievement Awards
in all academic & clinical areas.

REFERENCES: Available upon request

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