Ronald K Jones

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

Baltimore, Md, 21229

#443-***-****

E Mail: ac5t2x@r.postjobfree.com

Objective:

To secure a position with an organization utilizing knowledge of Medicare/Medicaid guidelines, medical review, project management, quality assessment, health care reform and nursing management/leadership skills.

Education:

Associate of Arts in Nursing

Summary of Qualifications:

Registered Nurse with 33 years of nursing experience

25 years of strong leadership and managerial skills

16 years of psychiatric nursing experience at state behavioral institution

12 years’ experience with Claims Review/ Utilization Review and Case Management

15 years Medical Surgical nursing

Manager for Medicare Advantage Health Insurance Plan

Supervisor of Medical Review team for Medicare contract

Supervisor for disease management company

Experience with Home Health Nursing and Geriatric Nursing in Nursing facilities

Computer skills utilizing Windows Outlook, Excel and PowerPoint

Supervising and administrating policy and procedure, timekeeping, project mgt

Liaison between DME, clinicians, pharmacies and clinics

EHS/EHR chart review/CPT/HCPCS coding experience

Scrum Master Training (11/2016)

Employment History

Aerotek Agency-2/2018- 4/2017. Inpatient medical review for Medicare product for Health care vendor. Contract completed.

Catapult Consultants-9/2017-11/30/17. Medical review of Part B Medicare claims for ZPIC vendor.

BroadPath Agency- 2/2017-7/2017 (contract-remote) managed team of nurses to organize Home Health and Hospice medical review services for Medicare Administrative Contractor and initiate Probe and Educate program for CMS vendor.

Arch Systems Inc- 10/19/16-2/2017 (contract)

Agile Nurse Review Lead of PQRS review team of skilled nurses. Responsible for analysis of health care measure data from the Physicians Quality Reporting System for validation criteria which would be used to evaluate the efficacy of the reporting data submitted from practitioners via EHR, EDQR and Claims reporting systems via EHS and chart review. Use of agile project management in a Scrum framework.

RSI agency- 7/2016- 10/2016 (contract)

Quality Improvement nurse at Riverside Health. Responsible for HEDIS measures and site visits, collecting data.

Telligen 10/20/15-7/2016

Manager of acute medical review services for Medicaid. Responsible for team of nurse reviewers and support staff delivering determinations for prospective, retrospective and appeals for Medicaid services.

Kaiser Permanente 05/18/2015-09/2015 (40-50 hrs per week)

Manager of Appeals and Correspondence Department. Responsible for team of Appeals Analysts, reviewing benefit appeals, member appeals and complaints and provider appeals. Clinical subject matter expert for medical necessity appeal.

Strategic Health Solutions 10/2013-11/2015 (40-50 hrs per week)

Supervisor for Medical Review. Manage team of medical review nurses responsible for post payment medical review of identified medical necessity and fraud /abuse claims for Centers of Medicare and Medicaid Services.

CareFirst Blue Cross Blue Shield 8/2012- 8/2013 (40-50 hrs per week)

Supervisor of 2 departments, (Quality of Care Dept and Clinical Medical Review Dept.) Responsible for utilization review RNs and support staff, (25), managing medical necessity pre-payment cosmetic and investigational claims. Responsible for management and review of member complaints, quality audits of providers and customer resolution regarding benefit parameters of Quality of Care department.

Use of Facets computer database.

XL Health Corp 6/2010- 8/2012 (40-50 hrs per week)

Manager of 18 RN case managers. Responsible for oversight of case management meeting Medicare advantage plan and Medicare guidelines under CMS. Responsible for Case manager metrics, attendance, time off, payroll and evaluations. Monitoring implementation and evaluation of S.T.A.R. measures and HEDIS data for review via Quality Team. Monitored disease teaching and training on Heart Failure, ESRD Diabetes and COPD. Use of Facets computer database.

XL Health Corp 4/2008- 6/2010 (40-50 hrs per week)

Case manager for Medicare advantage insurance plan. Managed benefits according to guidelines. Responsible for acting as liaison between health clinicians, ordering

DME and disease management to reduce hospitalizations

PB Home Health 6/2010- 4/2013 (weekend /per diem)

Provide Start of Care admissions on home bound patients per Oasis standards.

Evaluate care needs and provide and case manage skilled treatment.

XL Health Corp. 4/2007 - 4/2008

Supervisor of Disease Management

Responsible for supervision of 15 registered and licensed practical nurses in Disease Management Program. Monitored disease teaching and training on Heart Failure, ESRD Diabetes and COPD. Oversaw overall supervision of attendance, time off, payroll, evaluations, etc. Performed maintenance of work flows and technical issues. Responsible for productivity monitoring, call monitoring and analysis

Hospice of Baltimore Home Care Nurse 3/2006 - 3/2007

Provide case management services in home setting. Coordinated in care using multi-disciplinary approach. Physical assessment and symptom recognition. Disease/ Illness education. Coordination of care with primary physician. Use of Road Notes/Windows computer technology. Medication and pain management with required education.

Chesapeake Treatment Center Night Shift Supervisor 1/2006 2/2008

Supervisor of dispensary and infirmary for behavioral adolescent males.

Mariner Forest Hill Nursing Supervisor 7/2005 - 2/2006

Evening shift supervisor for skilled nursing facility.

Harford Memorial Hospital Charge Nurse 6/2004 - 6/2005

Evening shift supervisor for skilled nursing facility. Conducted group and individual therapy sessions

Roland Park Place Night Shift Supervisor 9/2003 - 4/2004

Residential care and skilled nursing unit

Medical Staffing Network Home Health 6/2001 - 9/2003

per diem medical surgical nursing for home health agency

Maryland Correctional Institute for Women

Health Services Administrator 10/1999 - 5/2001

Responsible for all medical staff and medical care for female population. Administrative duties as necessary. Coordination of ancillary services. Program audits, contracts, in-services, medical equipment monitoring.

Greater Baltimore Medical Center Medical/Psychiatric Unit 1/1999 - 10/1999

Medical and psychiatric admissions and intervention. Night shift unit charge nurse

Home Call Home Health Medical Intervention/ Case Management 1/1998 - 12/1998

Wound care. Infusion

Bon Secour Health System/LMC Mobile Treatment Services 4/1992 - 11/1998

Nurse Team leader and therapist in mobile psychiatric treatment team. Monitored of daily medication and group intervention

Maryland Correctional Institute for Women Mental Health Clinic 1990-1992

Crisis intervention. Special intervention and individual therapy

Maryland Psychiatric Research Center Research Nurse 1989-1990

Conduct double blind research studies. Operate schizophrenic clinic. Venipuncture and EKG monitoring.

Spring Grove Hospital Center Admissions Unit Supervisor/ Head Nurse 1982-1997

As Unit supervisor, responsible for 4 admissions units with census of 84 psychiatric patients.

As Head Nurse, responsible for nursing staff and patient care of 22 bed acute psychiatric admissions unit

* Certification Chronic Care Professional

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