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LPN.

Location:
Jordan, NY
Salary:
50,000
Posted:
June 30, 2018

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Resume:

Deborah J. Kolb

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

Tampa, FL 34677

***/***-**** (Cell)

***/***-**** (Home)

ac523d@r.postjobfree.com

Qualifications

Licensed Practical Nurse with hospital training, extensive experience in telephone triage, insurance referrals and medical office experience, insurance company experience, strong communication skills, ability to work as a team member, strong multi-tasking with accuracy, ability to work independently and efficiently.

Relevant Work Experience

LPN United Health Group-Optum

Case Manager

1/2/2014 to present

Currently in a telecommute position a Case Manager LPN assigned to 6 Long Term Care facilities, with a current caseload of 144 patients, in the Tampa Bay, FL area. I will plan weekly which facilities to visit and see the members that day Responsible for documenting your visits and assessments in the electronic medical records within 48 hours of seeing the patient. Able to identify and coordinate the appropriate levels of care under the direct supervision of an RN or MD. I am able to work autonomously and stay self-motivated, with little supervision.

Skills

Able to navigate through a Windows environment and to utilize Microsoft Word and Excel to perform data entry, sorting, & filtering. Able to Type 30 - 40 WPM. Have reliable transportation, valid and current driver's license, and current auto insurance, comfortable with 75% travel within the local area.

Knowledge of Medicare and Medicaid Experience with Care Coordination in a Long Term Care environment Experience with EMR (Electronic Medical Records)

LPN CARECENTRIX – HIT TEAM

CLINICAL REVIEWER for Florida Blue

4/29/2013 to present

Handles verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge. This position, using clinical expertise, receives/responds to incoming calls from referral sources/potential clients and CareCentrix Care Coordinators and performs administrative assessments of each referral's appropriateness for CareCentrix services. Researches/identifies all potential payer sources and determines the primary payer. Participates in utilization and quality assessment/improvement activities. Works under moderate supervision.

PRIMARY RESPONSIBILITIES

Using clinical expertise, reviews utilization information concerning patient care and matches those needs to available care options, within the CareCentrix guidelines and specific plan payer criteria.

Handles verification of all referrals funneled through Triage, verifying information, applying business rules and determining the next steps. Acts as a clinical resource to department care coordinators, providing expertise and clinical knowledge.

Receives/responds to incoming calls from referral sources/potential clients, exchanges information to identify the clients needs and determines CareCentrix' ability to meet them.

Receives and responds to requests from unlicensed staff regarding scripted clinical questions and issues.

Holds all referrals until all information is verified as complete and the next steps are determined.

Records the outcome of all inquiries and referral calls received, and makes follow - up calls when an inquiry or referral cannot be serviced. Tracks/reports on inquiries/referrals and identifies alternative resources when CareCentrix solutions are not available.

Performs an initial evaluation of the referrals appropriateness for CareCentrix services, researches/identifies all potential payer sources and determines the primary payer. Documents demographic/clinical/payer information and determines coverage availability for requested services and passes information on in a timely manner.

Recommends to Team Leader - Intake the acceptance of referrals that do not meet CareCentrix guidelines as appropriate. Coordinates internal activities to ensure a smooth transition from CareCentrix to the provider.

Develops/maintains a working knowledge of all CareCentrix services and accesses CareCentrix contract information, including the terms of the contract as appropriate. Interacts with referral sources to facilitate communications, answer questions and resolve problems.

Deborah J. Kolb

Resume

Page Two

LPN, ARTHRITIS HEALTH ASSOCIATES

July 2012 to April 2013

PRIOR AUTHORIZATION REVIEW NURSE, WELLCARE HEALTH PLANS, INC.,

July 2011 – July 2012

Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, outpatient services and out of network providers. Clinical Nurse Reviewer. Reviews medical records, uses clinical expertise and compares information to established guidelines and the members benefit plan. Works closely with departmental management staff to impact the treatment plan and identify treatment plan alternatives.

Utilizes WellCare designated criteria along with clinical knowledge to make authorization decisions and assist the Medical Director with review determinations.

Evaluates all requests for service to determine the Company’s financial liability including the collection of information regarding subrogation and COB and entry in the Health Service System.

Ensure accurate coding using CPT-4 and ICD-9 codes. Documents all information accurately.

Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information

Adheres to all confidentiality requirements

Applies medical knowledge benefits information to determine if requested services are a covered benefit

Arranges for transfer to in-network care when appropriate

Initiates process for Letter of Agreements for out of network provider requests that meet approval criteria

Identifies case appropriate for case management and makes appropriate referrals

Identifies potential quality of care issues and refers to the Quality Department.

Meets Service Standards for decision turn-around times and written correspondence

Performs special projects as assigned

Licensed Practical Nurse and Office Manager, Family Care Medical Group (John Eppolito, M.D.), Cato, New York

(2004-2011 )(1990-2002)

Duties include direct telephone triage with appropriate patient direction, patient scheduling, telephone call management, insurance referrals and authorization tracking, appropriate medical/surgical referrals as directed by Physician and patient call backs (i.e. tests results, follow up appointments.)

Ensure Patient compliance with HIPAA Laws.

Knowledge of immunization schedules, Flu Vaccines, Pneumonia Vaccines and TB Testing

Computer schedule maintenance, supply maintenance, personnel scheduling, attend office manager meeting

Extensive knowledge of private insurances, Medicare, Medicaid, Worker’s Compensation, No-Fault, CPT and ICD-9 codes.

Responsible for all business and personal correspondences. All data input.

Duties also include assisting patients with medication management.

Scheduling transportation for specialist appointments.

Maintaining open communication between physician and patients’ families.

Maintaining accurate medical documentation.

Medical Research, Bottar and Leone Law Firm, Syracuse, NY

(3/2006-2011)

Prepare medical chronologies of clients medical charts/Prepare medical provider lists and dates of service

Summarize and describe medical services provided by MD’s and ancillary services

Order necessary medical files as per HIPPA protocol

Organize findings for presentation to partners

Deborah J. Kolb

Resume

Page Three

Clinical Research Coordinator, SUNY Upstate Medical Center, Research Foundation

(2002-2004)

Responsibilities include extensive subject contact and accurate documentation of all subjects’ events and medications pertaining to the study protocols. Clinical Coordinator responsible for seven research studies

Duties include triage, data management, time management, scheduling Diagnostic tests, maintenance of accurate records for study medication

Extensive knowledge of HIPAA laws, GCP rules and FDA requirements for study protocols

Preparation of Informed Consents and Grant Applications for submission to IRB and the study sponsor for approval

Travel to Investigator Meetings, relaying appropriate information to study personnel. Obtaining approval from the Clinical Research Unit for the use of the facility for research study

Educating study personnel regarding research protocol and preparing orders for the Principal Investigator’s approval

Consenting of all study subjects prior to enrollment with assurance of their complete understanding of the study protocol and expectations of their involvement in the research study

Responsible for reporting to Institutional Review Board any changes in the study Protocol, Informed Consent, adverse events or protocol deviations, maintain open communication with Principal Investigators, study sponsors and Institutional Review Board

Extensive written and computer communications.

Maintain telephone contact with all study subjects, study sponsors and IRB with documentation

Communicating all correspondences to the Principal Investigator

Preparation of budget to the Clinical Trial Office for research studies

Skills:

Medent (extensive), Windows Outlook, Medical Terminology, Data Entry, EMMA, Interqual, CAIS, BRIO, EMR and GroupWise. Next Gen.Care One

Education

CME Credits at SUNY Upstate Medical University

Cayuga County Community College – Chemical Engineering Program

BOCES Practical Nursing Program/ Boards -- Practical Nursing License

Cayuga County Community College -Liberal Arts Program

Licenses:

New York State and Florida Practical Nursing License;

Certifications:

Medical Coding ICD-9 and CPT; CPC Nationally Certified

Phlebotomy for the Medical Professional; Certification



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