Medical Care
Resume:
EDNA L. Williams, LPN
***/***-**** *********@*******.***
Experience
PROFESSIONAL SUMMARY:
Professional Licensed Practical Nurse with 15+ years of nursing experience
5+ years of Utilization and Compliance Review, Quality Assurance, HEDIS, Prior Authorization, and Retrospective Review experience
Analyze, review documentation per established guidelines, policies and procedures.
Evaluated, educated and administered medication and therapies
Billing and coding: Utilized ICD-9 and ICD-10 CM manuals and other reviewing tools
Knowledge of marketplace claims/denials and CMS/NCQA guidelines for appeals and denials
5+ years of experience using McKesson Interqual
Ability to quickly determine and perform the best care possible in critical and sub-acute care settings
Ability to work independently, efficiently, timely and within departmental budget.
Healthcare Scouts 02/2017 – 04/2017
QI Specialist
Reviewed chart documentation for a project, required for NCQA HEDIS.
Collected and reviewed documentation from various Healthcare Providers and PCPs
Determined the level of coordination of care between PCP and Behavioral Health Providers
Input all obtained information to database using Microsoft. Powerpoint, Word
Inovalon (Med Assurant) 07/2015 - 08/2016; 12/2012 – 11/2014
Site Review Consultant
Coordinated with providers to collect designated clinical information.
Worked independently, accurately and efficiently conducting medical record review/abstraction services; worked from home doing remote abstractions; the ability to multi task.
Scanned relevant components of the medical record to support reviews performed.
Electronically downloaded review assignments to the laptop and data collection tool; daily uploaded completed assignments and scanned medical records.
Completed quality, accuracy and inter-rater reliability testing as requested in a timely manner. Ability to manage and meet deadlines.
Communicated effectively and professionally with care provider offices, clinics, hospitals and other clinical facilities.
Used the ICD-9 and ICD-10 CM manuals and other reviewing tools.
Travelled throughout Southeastern Michigan to physician offices, hospitals and clinics.
Made confirmation phone calls to confirm scheduled appointments.
Entech Staffing 11/2014 – 01/2015
Telephone triage/Prior authorizations
Reviewed and authorized continued care based on the McKesson InterQual criteria.
Made sure reports were accurate for the Appeals department.
Maintained department productivity and quality measures.
Authorizations for DME, outpatient and inpatient surgeries.
Coordinated care plans and referred cases to medical director.
Collected and reviewed all telephonic information for appropriate care.
Worked as temporary staff.
St Mary’s Nursing and Rehab Center 02/2008-07/2010; 02/2011-04/2013
Nurse Supervisor
Managed the health and safety of a 23 bed resident unit specializing in elder care.
Created, initiated, and facilitated care plans that were individualized and holistic driven by the desire to maximize independence and quality of life.
Demonstrated an ability to communicate with residents inflicted by various degrees of dementia and/or psychiatric conditions.
Supervised the care/services provided by the Certified Nursing Assistants and other staff who provided services to the residents.
Evaluated, educated and administered medication and therapies dynamically to ensure the optimal health for the individuals and their families.
Ability to quickly determine and perform the best care possible in critical and sub-acute care settings; documentation of medical information.
Supervision of nursing and assistants and other facility workers in the care of patients.
Performing day-to-day administrative tasks such as training patients, family members or caregivers in techniques for managing disabilities or illnesses.
Molina Healthcare of Michigan 11/2004 - 12/2009
UR Nurse/Referral Coordinator
Telephonic triage/Prior authorizations for DME, outpatient and inpatient surgeries.
Reviewed and authorized continued care based on the McKesson InterQual criteria.
Made sure reports were accurate for the Appeals department.
Maintained department productivity and quality measures.
Provided education on medical devices and disease management; including diabetes, COPD, CHF, GI treatment.
Coordinated care plans and referred cases to Molina medical directors per organizational policy.
Maintained documentation in accordance with HEDIS and NCQA standards and policies.
Worked within the department’s budgets.
Maxim Healthcare Professionals 2/2002 – 12/2008
Staff Relief Nurse 7/2002 -2/2008
Provided temporary staff relief in nursing homes and flu clinics.
Total patient care including the administration of medication, assess patient’s physiological, emotional and social needs.
Ability to quickly determine and perform the best care possible; documentation of medical information.
Supervision of nursing and assistants and other facility workers in the care of patients.
Provided patient care in critical and sub-acute care settings.
Educated patients and their families on disease processes.
Education
Bachelor of Business Administration, Northwood University, Midland, MI
LPN-MDTA School of Practical Nursing, Detroit, MI
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