Manager Case
Resume:
Betty Brown, BSN, RN, CCM
***** ******* ******, ***** *****, IN 46307
******.*****@*****.***
https://www.linkedin.com/in/bettybrownccm
PROFESSIONAL SUMMARY
Client focused Certified Case Manager with extensive experience in the health care industry, including Medicare, Medicaid and commercial insurance. Experiences include Claims Processing, HEDIS Review, Complex Case Management and Utilization Reviews using Interqual and MCG.
EXPERIENCE
Advocate Health Care- Chicago, IL (December 2016- December 2017)
Utilization Review Nurse
Responsible for initial, continual stay, retro reviews and in house denials utilizing MCG.
Responsible for determining the correct level of care.
Respond to requests for clinical documentation from Payers.
Collaborate with Physician Advisor’s and Attendee to ensure timely orders for appropriate changes in level of care.
Family Health Network- Chicago, IL (January 2015–July 2016)
Clinical Education Specialist (Case Management Trainer)
Responsible for new hire orientation and ongoing education/training of clinical and non-clinical employees, vendors and providers. Developed training manuals, job aids, how to guides, pre and post-tests, acknowledgment forms and evaluations
Responsible for teaching myself the companies new case management and member account system, developing and implementing training manual for the new system, coordinated the training of clinical and non- clinical staff on the new system, as well as other software programs, including grievances software, Skype and Outlook
Collaborate with departmental managers to identify educational needs of their departments and ways to improve performance
Assisted Manager of Education with interviewing process and selection of staff for positions within the education department
Served on company Educational Committee (developed company educational material)
Case Manager (Care Coordinator)
Mentored team of less experienced Care Coordinators
Preceptor of newly hired Care Coordinators
Conducted chart audits of the Care Coordinators against NCQA standards
Comprehensive assessments, created member centered care plans, coordinated referrals, authorizations, stratified members risk levels and completed discharge assessments to identify and address member’s post-acute discharge needs, provided member education on disease states, scheduled medical appointments
Participated in health fairs for our members to educate and close HEDIS measures
WellCare Health Plans, Inc. – Tampa, FL (June 2012 to December 2014)
Complex Case Manager (Utilization Review)
Outreached Medicare and Medicaid members to educate on and enroll in Case Management program. Provided member/caregiver education on disease states
Completed assessments, member centered care plans, coordinated referrals and authorizations, discharged planning including home health and equipment
Scheduled appointments
Documentation based on NCQA standards
Medical reviews using Interqual for medical necessity for members in Case Management program.
HEDIS Review Nurse
Telephonically outreached Medicaid members with missing HEDIS measures
Educated member’s on missing measures, importance of the measure and scheduled appointments to close the gap
Completed assessment to identify medical needs of member and referred member to other departments as needed (Disease Management, Case Management, Behavioral Health)
Educated providers on missing HEDIS measures
Florida Hospital –Tampa, FL (March 2011- April 2012)
RN Staff Nurse Medical /Surgical / Telemetry
Observation, assessment, planning, intervention and evaluation of patients care
Patient teaching/counseling and patient advocate, admissions, discharges and float team
Administration of medication, treatments and procedures as ordered by the physician
Part of the float team, floated to neuro and post-op orthopedic units
Professional Case Management – Tampa, FL (February 2011-November 2012)
Home Health/Private Duty Nurse
Observation and assessments of home bound chronic and terminally ill patient’s
Tube feedings
Tracheotomy care
Infusions
Caregiver education
Medication administration
Wound care
Lab draws
Vitals
Documentation
Aetna Health Plans- Tampa, FL (September 2003 to January 2006)
Claims Adjudicator/Service Consultant
Adjudicated claims for commercial plan members
Answered inbound calls from plan members, regarding benefits, eligibility, claims, coverage and plan specifics
EDUCATION/CERTIFICATION
Associates of Science in Nursing-Saint Petersburg College (2008)
Bachelors of Science in Nursing -University of Texas at Arlington (2013)
Certified Case Manager (CCM) -The Commission for Case Manager Certification (2014)
RN License in FL, IL, IN and CA.
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