Registered Nurse Quality Assurance

Victoria Buchanan, RN, BSN, CCM, MBA

P.O. Box *3051

phone: 913-***-****

Overland Park, KS 66283

email: *****************@*****.***

HEALTHCARE MANAGEMENT QUALIFICATIONS

Registered Nurse with 13+ years' experience in the healthcare industry.

Expertise in utilization management, strategic planning and analysis, cost-

containment, process and performance improvement, and IT design and

implementation.

Diverse background in Case Management, Quality Assurance, Critical Care,

Home Health, and the start-up of three Hospice organizations. Strong

management, computer, organization, presentation, problem-solving, staff

training and leadership skills. Demonstrated success in designing,

implementing, and re-vamping processes and computer applications that

reduce costs, improve efficiency, communication, and quality of care. Case

management experience with strong knowledge of Medicare, Medicaid,

Commercial and Self-funded Insurance plans.

Windows Vista; Microsoft Word, Excel, Outlook, Power Point, Visio;

Interqual; CCA; Suncoast Solutions; RIMS; Pharm Screens; Patron; PIM; Care

Manager; HMS+; Amedisys; Lewis; Home Base; 90+ wpm.

PROFESSIONAL EXPERIENCE

Case Manager - Senior Products Humana Inc., Overland Park, KS

May 2007 - present

. Top Case Management and Utilization Review Nurse for Medicare

Advantage HMO, PPO and FFS Medicare Advantage and Medicare Group Plans

. Consult with the Regional Medical Director regarding Catastrophic

Cases and prior auth requests

. Negotiate letters of agreement with non-contracted providers

. Team lead for Worksmart program and trainer for new nurses

. STAR Award

. Kansas City Benefits 2009 Judge

. Corporate CGX forms committee member, MOIC Subject Matter Expert;

troubleshoot new software enhancements

Nurse Case Manager American Trust Administrators / Tactical Stop

Loss February 2006 - May 2007

. Responsible for overseeing the Case Management Program for a TPA

servicing over 6,000 members

. Prepare monthly comprehensive claims reports to the Executive Staff

for group renewals

. Process inpatient and outpatient Pre-cert reviews for all members

. Negotiated rates for DME, medical supplies and ancillary services

Consultant, Director of Clinical Services Lighthouse Hospice, Tulsa, OK

January 2005 - February 2006

. Established and executed the scope, design, customization,

implementation, and training of Suncoast Solutions, a complex

paperless software application which synchronizes mobile databases for

documentation in the field

. System maintenance of server agents, system upgrades, drugs, forms,

PIO's (care plans), MSA and billing codes

. Provided technical support to all staff regarding troubleshooting

problems including day-to-day operations; security and login roles;

subscription and replication of data from the laptop(s) to the main

server/superbase using LAN and remotely using high speed VPN or cell

phone connection

. Developed quality assurance tools used to audit clinical records and

monitor patient care standards in compliance with the plan of care,

State, Federal and agency requirements

. Supervised clinical staff to ensure cost-effective interventions and

compliance with the plan of care

. Led Interdisciplinary Team Meetings and collaborated with the Hospice

Medical Director regarding end-of-life care and support for patients

and their families

. Tailored numerous reports and spreadsheets to assist in

staffing/schedule, census, payroll, calculation of patient care and

volunteer hours, calculation and reconciliation of accounts payables

and cost-containment

Victoria Buchanan, RN, BSN, CCM, MBA Page 2 of

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Case Manager, Discharge Planner Bristow Medical Center, Bristow, OK

March 2004 - January 2005

. Directed and implemented the plan of care of home health clients from

admission to discharge; ensuring cost-effective, quality outcomes and

appropriate referrals to internal and external agencies

. Assessed hospitalized patients to determine discharge needs and

coordinated referrals for continued care, durable medical equipment,

supplies and other eligible community resources

. Evaluated high risk patients treated in the emergency room for

compliance with discharge instructions, customer satisfaction and

continued health care needs

. Recruited to conduct audits of medical records to meet clinical

standards of care

Care Manager, RN - KY Medicaid Department BCE Emergis, Louisville, KY

August 2002 - March 2004

. Directed pre-certification and ICD-9/CPT coding for acute

hospitalizations; scheduled inpatient surgical procedures; long term

care admissions; Acquired Brain Injury Program and Home Community

Based Waiver Program eligibility encompassing patients from every

specialty area including: Labor and Delivery, Neonatal, Pediatrics,

Oncology, Urology, Transplant, Trauma, Orthopedics, Neurology,

Geriatrics, Psych and Critical Care

. Recruited as clinical resource to pilot program for IT team to

propose, implement and troubleshoot enhancements to computer software

application and conversion from a paper system to a new electronic

filing system which significantly improved efficiency and speed of

clinical reviews as well as a means to organize, store and retrieve

data

. Developed training materials for new computer systems customized to

daily operations of clinical staff

. Recognized as top performer for department averaging 60-100+ clinical

reviews / day and earning Emergis Ellite Nomination, a corporate wide

award for excellence, and the highest evaluation rating within

department.

ICU RN, Quality Assurance Auditor Baptist Hospital East,

Louisville, KY December 2000 - November 2003

. Provided direct nursing care to critically ill patients with complex

health care needs including ventilator management, multiple IV

infusions with titration, external ventricular drains, ICP monitoring,

conscious sedation and post-operative monitoring, ECG monitoring, Swan

Ganz Catheters, Central Venous Lines and Continuous Renal Replacement

Therapy

. Performed audits of medical records for quality indicators and

formulated educational materials for staff based on analysis of

findings

EDUCATION

Masters in Business Administration MidAmerica Nazarene University

Completed October 2010

. 3.84 Cumulative GPA

Bachelor of Science in Nursing Langston University, Langston, OK

Completed December 2000

. 3.453 Cumulative GPA

. Magna Cum Laude and Dean's List

. Award for "Professional Achievement in Professional Excellence"

Wound-VAC Certification and numerous competencies in hospice, home health,

and critical care

BLS for Healthcare Providers (CPR & AED)

Case Management Certification

LICENSURE

Active Registered Nurse License in Arkansas, Kansas, Missouri, Colorado and

Oklahoma

Contact this candidate