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Manager Nurse

Rancho Cordova, California, United States
June 24, 2018

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**** *** ******** ***, ****** Cordova, CA 95670 916-***-****


Registered in State of California (#495757)

National Association for Healthcare Quality (NAHQ), Member

American Health Information Management Association (AHIMA) Data and Information Analysis Task Force 2015-2017 Volunteer Contributor and Co-Author: “Assessing and Improving EHR Data Quality” Practice Brief (p. 58-64, May 2015) and “Data Quality Management Model Practice Brief Update”(p. 62-65, October 2015)

Computer Skills: Microsoft Word, Excel, Visio, PowerPoint, WebEx, MIDAS +, EPIC, CERNER, and OASIS


Supervisor, Clinical Appeals Unit, Optum360/Dignity Health – Interim Sept 2016 –Mar 2017) & Sept 2017 to Present

Rancho Cordova, CA (Telecommute)

Responsible for managing a team of 10+ clinical appeal nurses and up to five appeal administrative coordinators.

Responsible for providing clinical expertise in clinical appeal analyzing, reviewing and evaluating

Oversee clinical appeal writing for up to 35+ facilities within nine regions in CA, NV and AZ for client Dignity Health, and responsible for an appeal inventory range of 750 – 1,500 cases over past year.

Analyst for clinical appeal unit dashboard metrics and appeal outcome reporting to demonstrate of month over month and year over year total appeal dollars recovered, totaling projected $90+ million per year on average.

Monitor, establish and review clinical appeal nurse and administrative support staff metrics and productivity targets. Set priorities for task completion.

Establishes team direction and priorities, resolve problems and provide guidance to team.

Adapt department wide and client based plans and priorities to meet business and operational challenges.

Forecast and design team strategy and planning activities. Analyze and identify trends for appeals and grievances.

Designed Clinical Appeal Unit Organizational database to support multiple software systems used to analyze details and clinical information to support appeal process and to reference department specific processes for KL.

Provide clinical training to support appeal writing process.

Clinical Special Projects – Managed algorithm development, analytics and support and insight for outcomes, measurement standards and delivery methodologies focused on quality, affordability and outcomes to drive a streamlined and focused clinical appeal process.

Sr. Case Manager/Audit Management Nurse, Optum360/Dignity Health 2013 - 2017

Rancho Cordova, CA

Collected, analyzed, abstracted and interpreted healthcare data and performed analysis of clinical documentation and contractual issues related to clinical denials. Adhered to appeal time frames to recover payment for medically necessary services. Expert knowledge of Capitation, DOFRs, Managed Care, Medicare, Medicaid, GMC, and third-party payer contracts.

Wrote letters and provided supportive documentation to appeal medical necessity and level of care denials from multiple commercial and government health plans., including UHC UMR, Managed Medicaid, Managed Medicare and state funded plans based in CA, AZ and NV.

Trauma appeal subject matter expert. Advanced knowledge of stop loss denials and contractual guidelines.

Apply quality and system improvement initiatives and root cause analysis for performance improvement tracking for >20 hospitals. Adhered to strict timely filing deadlines.

Utilize case management process to conduct clinical inpatient and outpatient reviews based on established

treatment criteria, including continuum of care planning, risk assessment, discharge planning process, referrals for outside agencies or facilities and evaluate coordination of transfers.

Quality Liaison for Medi-Cal audit project to review authorization and payment compliance with state/federal and local policies (2015).

Worked collaboratively with peers and communicated with vendors to ensure smooth transition of services Communicate and report denial trends; evaluate and advise corrective actions.

Performed audits based on internal P&Ps and to ensure compliance with SOP and state/federal regulatory protocols and requirements. (CMS).

Analyze and integrate complex data to complete to achieve desired clinical, operational, and financial outcomes. Provide expert application of evidenced based medical necessity criteria tools.

Provided complex review/analysis, including Adult Med/Surg, Geriatric, Trauma, Maternal/Child, NICU and Pediatrics.

Utilized Adv. Excel, InterQual, Milliman MIDAS, Veracity, Artiva, Cerner, Meditech, MS4, Healthport, Healthlogic, etc., and multiple electronic medical record formats to consistently review all levels of care and medical necessity denials for appropriateness based on established criteria.

Clinical Nurse Analyst, Quality Liaison, CPOE, Orders & Documentation Team 2010–2013

Adventist Health – Roseville, CA

Developed, conceived, planned, tested, and implemented software and related computerized information service solutions. Performed work-flow analysis and process redesign, engaged in quality control, and facilitated change management and staff training. Utilized expert knowledge of quality tools. Wrote several business and clinical process improvement initiatives.

Project Manager – Prioritized opportunities for improved processes and lead effort to determine readiness for CORE measure software implementation. Programmed, formulated, and supervised the installation of National Hospital Inpatient Quality Measures (NHIQM) and NCQA accreditation to direct and refine goals of quality programs to increase efficiency and reduce errors for 17 hospitals.

Supervised and trained staff as project manager to institute new upgraded computerized systems for 17 hospital sites to comply with federal regulations (i.e. CMS, CDC, Core Measures and Meaningful Use), including successfully forecasting and implementing project timelines.

Case Manager/Public Health Nurse Consultant Child Health and Disability Prevention Nurse (CHDP) 2006-2009

County of Sacramento – Sacramento, CA

Utilized government and facility-established protocols to offer case management services for medically fragile foster care children, directly supervising team of 5 to 10 home caregivers. Oversaw physical, behavioral, medical, dental, and developmental needs of pediatric clients.

Recuperation Skills Training Center (RSTC)/Nurse Instructor, Advice Nurse 1998–2006

Kaiser Permanente – Vallejo, Roseville & Sacramento, CA

Coordinated continuum of care services in conjunction with Patient Care Coordinators to administer risk assessments and provide individual and family teaching at the bedside and clinic settings for self-care skills needed after discharge, or diagnosis with a health condition requiring specific treatment intervention.

Designed handouts and reference booklets for home care with senior clinical staff and chief medical officers.

Lead Nurse Educator covering weekends for Kaiser Sacramento (Morse) and Roseville Facilities.

Developed care plans and initiated referrals to physicians and community support services based on individual need. Assisted in discharge planning process.

Medical/Surgical Nurse 1994-1999

Veterans’ Home of California, Yountville

Responsible for assessing, planning, prioritizing, organizing, administering, and evaluating patient care on the acute medical surgical unit, ICU, transitional care, and ambulatory care units.


M.S. Nursing Informatics, Capella University (Anticipated Graduation Date: June 2018)

B.S. in Nursing & Public Health: Holy Names University, Oakland, CA (GPA: 3.83–Magna Cum Laude)


National Association for Healthcare Quality (NAHQ), Member 2010 – Present;

American Health Information Management Association (AHIMA), Member (2013 – Present)


-Nominated as a 2016 Superhero for Optum Insight customer operations, including >10,000 worldwide employees.

-Selected to represent Optum360 at AHIMA 2015 HIM convention to present case management strategies and root cause analysis as key component to denial prevention.

-Top producer for 2nd quarter 2013 and 1st quarter 2015, Dignity Health, Clinical Appeals Unit, recouping > $20 million in lost revenue for three service areas: Sacramento, Southern California and West Bay.

-Authored CPOE Medication Reconciliation, Adventist Health Policies (Nov 2010); coauthored Documentation Guiding Principles, Adventist Health Policies (Dec 2010); coauthored Mastectomy Guidelines for Home Care (Kaiser Permanente, 2005); and authored ABC’s of Hand Washing pamphlet. Presented at NHIQM Kick Off, Adventist Health (2011)

-Nominated by University of California, Riverside, for the “Nursing Case Management Rising Star Award,” Winter Quarter, 2013, including feature spotlight in the upcoming course certificate program catalog.

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