Virginia L. Stiles

**** ****** **** *** ****

Austin, Tx 78745

504-***-****

E-Mail: abqxsu@r.postjobfree.com

SUMMARY OF QUALIFICATIONS

Seasoned nurse case manager with 20 years in case management, utilization review and discharge planning for major health insurance companies and ten years clinical experience in skilled nursing facilities and hospitals. Proven cost savings to the health care payer through utilization review, negotiation, discharge planning and chart review. .

PROFESSIONAL EXPERIENCE

Nurse Case Manager

American Mobile Healthcare

Assignment: Scott and White Memorial Hospital 2401 S. 31st Street. Temple, Tx November 26, 2012 to present

Review all Observation cases to determine status

Review medical records of Insurance, Medicare,Medicaid and non insured patients

Utilize Interqual Criteria to determine inpatient vs observation status

Refer cases to medical director that do not meet the interqual criteria

Nurse Case Manager

Ochsner Foundation Hospital 1514 Jefferson Highway. New Orleans, LA April 2008 to October 12, 2012

Review charts on Oncology floor to ensure the correct bed status is assigned

Concurrent review of Insurance, Medicare, Medicaid and non insured patients

Work directly with social worker, family and MD to develop a safe discharge plan.

Utilize Interqual Criteria to justify medical necessity

Case Manager

Northwest Hospital and Medical Center, Seattle, WA 2005 to 2008

Reviewed and conducted concurrent utilization review of patients on Orthopedic floor

Obtained approved days for insurance companies

Reviewed Medicare charts for appropiate documentation, communicated with Dr's

Abstracted charts for the CMS SCIP measure, and reported results quarterly

Worked closely with surgery re CMS measures and compliance

Onsite Utilization Review Nurse

Peoples Health Network New Orleans, LA 2000 to 2005

Managed all members that were inpatient at St Charles General Hospital through discharge planning

Worked closely with the Physician,Family and social worker to develop a safe discharge plan.

Attended rounds with the hospital's medical director to discuss complex cases

Case Management Coordinator

Zenith Administrators, INC., Seattle, WA 1997 to 2000 /1992-1995

Perform case management for home care patients, including contract negotiation.

Identify/manage catastrophic and large dollar cases.

Conduct concurrent utilization review of hospitalized, home health care and skilled nursing facility cases.

Utilize PRO-West criteria to authorize medical necessity of continuing inpatient authorization.

Work directly with discharge planner, social worker, family and MD to coordinate timely and appropriate discharge from hospital.

Educate policyholders, physicians and hospitals regarding individual benefit coverage.

Pre-certify surgical procedures and hospital admissions.

Perform retrospective review of hospital records.

Manage fifteen different health care plans, notifying and working with the reinsurance on large dollar cases.

Care Management Coordinator

Blue Cross Of Washington State & Alaska Mt.Lk. Terr. WA 1995-1997

Utilized Milliman and Robertson Criteria to determine medical necessity of continuing inpatient authorization.

Nurse Consultant

Aetna Health Plans Seattle, WA 1992-1992

Utilized Interqual criteria

Benefits Coordinator

Great Republic Life Insurance Company Seattle, WA 1989-1992

Registered Nurse

Northwest Hospital Seattle, WA 1986-1993

Worked primarily on medical/oncology unit.

Administered medications, including chemotherapy and adjunct protocols.

Counseled patients and families regarding illness and assisted in grief process.

Coordinated and provided primary care for up to six patients.

Assisted patients with both physical and psychosocial needs.

Functioned as part of interdisciplinary team in patient care conferences.

Drafted unit protocols as a member of Policies and Procedures Committee.

Nursing Assistant, Float

Psychiatric technician, Psychiatric Unit

Unit Secretary, Psychiatric Unit

Stevens Memorial Hospital 1984-1986

Performed basic patient care on all medical floors

Independently charted inpatient medical records

Coordinated basic unit secretarial functions, including assignment of new admit, computer data entry, telephone management, transcription of physician orders.

COMPUTER SKILLS

Proficient IBM skills on Word, Excel and Publisher.A quick learner on all software programs. Assist other staff with computer problems. Able to research and find information on the Internet.

EDUCATION

Associate Sciences, Registered Nurse, Shoreline Community College, Seattle, WA

PROFESSIONAL MEMBERSHIPS

Washington Medical Case Management Association (WMCMA)

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