Medical Management

Dorothy Six

P.O. Box ****

Tampa, FL ***** Phone: 813-***-****

Email: abj5tb@r.postjobfree.com

SKILLS

Accumulated experience in healthcare medical management: appeals,

interaction with regulatory entities, utilization.

OBJECTIVE

To excel in a challenging position, allowing me to utilize my skills and

strengths while ensuring excellent production and quality.

management, resolution of provider issues. Excellent work ethic.

EXPERIENCE

Citrus Healthcare - Tampa, FL

01/10 - Current. Appeals & Grievances Specialist. Coordination,

investigation & processing of appeals/grievances for all lines of business

with strict adherence to CMS, AHCA & URAC guidelines. Submission of cases

for independent peer review &/or to the I.R.E.

3/09 - 9/09. Prior Authorizations (Pre-cert) Nurse, Medical Management.

Facilitation & submission of provider requests to medical director.

3/08 - 2/09 Initial Clinical Reviewer (Prior Authorizations Nurse),

Medical Management . Intake, facilitation via entry and notification of

medical referrals/authorizations submitted by providers. Extensive use of

InterQual criteria and CMS guidelines with basic knowledge of medical

billing/coding. Performance within regulatory guidelines; URAC, CMS, AHCA.

Coventry Healthcare - Tampa, FL

10/07 - 3/08. Customer Communications Specialist, WC Priority Projects .

Facilitated resolution of provider issues related to contract and billing

errors. Use of various proprietary software programs as well as spreadsheet

manipulations using Excel.

Maxim Healthcare - Tampa, FL.

2000-2004. Field LPN. Responsibilities included direct patient care in

the home for severely debilitated children; medication administration,

documentation, and communication with patient family and members of the

healthcare team.

Occupational Health Services, University Community Hospital / Carrollwood,

- Tampa, FL

1997-2000. Asst. Care Coordinator. Telephonic case management of

clients' treatment with extensive communications with patients,

employers, insurance representatives, and healthcare team.

Tampa Metro Treatment Center - Temple Terrace, FL

1995-1996. LPN. Administration and observation of medication for clients

including absolute accuracy and accountability for inventory and control of

medications in an outpatient treatment environment. Computer documentation

and inventory, assessment, observance of security measures

.

EDUCATION:

Hillsborough Community College, Tampa, FL - Part time attendance.

University of South Florida/Continuing Ed. Tampa, FL - COBOL, Y2K Cert.

June 1998

Hillsborough Community College, Tampa, FL - Part time student, Gen. Ed.

1994-1996

Erwin Technical Center, Tampa, FL - Practical Nursing Cert. March 1991,

Honors, License June 1991

Western Kentucky University, Bowling Green, KY - Part time student, 1976-

1979

SALARY REQUIREMENT $50,000.

SUMMARY

Multi-talented, adaptable candidate with approximately fifteen years

combined experience in healthcare/managed care with excellent skills.

Contact this candidate