Registered Nurse Manager

Karen Luminarias-Perry BSN, RN, RHC-*

***** ********** **.

Wesley Chapel, FL 33544

Cell: 813-***-****

Email: **********@*****.***

Professional Background

Highly motivated and energetic with 15+ years experience in customer care/nursing experience

Skill Highlights

•Call Center experience

• Phone Communication/Call Center

• Quality Audits/Data Analysis

• Staff Training

Professional Experience

RN Quality Analyst-Genzyme, November 2016-present

Amerisourcebergen-Lash Group Clinical Services

•Conduct call monitoring and case file reviews

•Provide training for associates

•Participate in call calibrations to ensure credibility of the quality monitoring scoring process

•Provide management with daily, weekly, and month end quality results

•Participate in client meetings

•Prepare agenda and/or take meeting notes

•Identify client issues; receive and triage client requests

•Create/Update Work Instructions and/or Job Aids

Appeals RN-Lundbeck, Oct 2015-November 2016

Amerisourcebergen-Lash Group Clinical Services

•Review clinical documentation to support an appeal for the patient.

•Intake and report adverse events.

•Generate appeal letters to be used to request payer coverage for the medication.

•Submit appeal to specific payer.

•Track progress of the appeal until determination is obtained.

•Assist in training via Skype/Microsoft Lync

•Assist in quality audits.

•Assist in creating Work Instructions, Job aids, and SOPs.

•Assist in Lundbeck adherence programs.

Nurse Manager of Field Nurse Educators for Multiple Sclerosis Field/Telehealth program

Amerisourcebergen-Lash Group Clinical Services, Feb 2015 to Oct 2015***program closed on 10/30/15

• Implements and ensures that processes are in place to monitor quality and program compliance

•Conducts performance reviews

•Coaches, counsels and sets goals for Tele-Health Educators to help develop them for career progression

•Participates in the hiring and termination process; identifies staffing needs and works with HR to recruit appropriate staffing

•Maintains Sharepoint site

•Provides virtual training for associates via Microsoft Lync, Adobe Connect

•Provides input into incentive plan performance metrics

•Helps associates resolve work-related issues

•Participates in client meetings; prepares agenda and/or takes meeting notes

•Identifies client issues; receives and triages client requests

•Quality chart/call audits

•Assists Senior Nurse Manager in monitoring, reporting, and maintaining KPIs

•Assists Senior Nurse Manager in program document management-revision of Work Instructions, Job Aids and

SOPs

Care Manager, December 2014 to February 2015

Humana at Home

• Proactive telephonic outreach to eligible Humana members and engage participation in Humana At Home Complex Care Management program.

• Provide care coordination and education on preventive screenings (HEDIS measures) to Medicare members (complex and non-complex cases)

• Complete physical, psychological, emotional and environmental assessments, for the purpose of providing appropriate, timely interventions to ensure provision of optimal care.

• Coordinate community care and services as deemed appropriate.

• Works Collaboratively with other members of the Humana At Home Interdisciplinary team-to include; Humana At Home Care Managers-Social Services, Field Care Managers and Community Health Educators.

Frontline Leader-Health Planning and Support, Dec 2013 to December 2014

Humana

• Provides supervision in a call center environment of staff performance to include: mentoring, auditing, productivity, monitoring, training and coaching for success.

• Monitor daily operational performance relating to Inbound call metrics and Service Level Agreement requirements.

• Analyze reporting data trends within team relative to metrics to maximize efficiency and productivity.

• Review department’s key performance indicators (KPIs) for improving work, processes, and policies to increase performance success

• Collaborate with leadership team on evaluation and revision of workflow processes and policies and procedures.

• Support Process Manager’s requests and prioritize by urgency.

• Participate in department hiring and retaining talent

• Manage VAT (Voice Activated Technology) Campaigns i.e. ER VAT, Medication Adherence

Team Leader-Senior Case Management, August 2013-December 2013

Humana

• Assist the frontline leader and manager in leading the Case Management Team in accordance with policies and procedures and are responsible to support the daily operations of the department

• Shares their knowledge base of health care delivery systems and benefit plans with the Case Management Team.

• Provide timely responses to associate questions and requests.

• Precepting and mentoring of associates/reassignment of duties if associate is out unexpectedly.

• Stands in for front line leader when front line leader not available and can follow through with issues or escalate if necessary.

• Maintain Sharepoint site for Case Management team.

• Provide care coordination and education on preventive screenings (HEDIS measures) to Medicare members (complex and non-complex cases)

• Perform assessments such as HOHS and CAHPS surveys.

Senior Case Manager, Oct 2012-August 2013

Humana

• Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design

• Educate Medicare members about their chronic disease processes and preventive screenings (HEDIS measures).

• Recommend services for Humana Plan members utilizing care alternatives available within the community and nationally

• Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols

• Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria

• Conduct admission review, post-discharge calls and discharge planning

• Perform assessments such as HOHS and CAHPS surveys.

Health Screener Contractor (Contract Work), March 2013-February 2014

CIA Health Screening

• Conduct health screenings-blood pressure, BMI, A1c, Glucose, Cholesterol, and TSH/PSA.

• Health coaching

Clinical Communication Center Nurse, August 2012-Oct 2012

Inovalon

• Communicate with patients, providers, and caregivers to obtain or provide information,

including completing telephonic health counseling and education calls as they relate to HEDIS/STARS measures.

• Provide disease-specific education in accordance with corporate policies, procedures and program

content;

• Adhere to all confidentiality and HIPAA requirements as outlined within Inovalon’s Operating

Policies and Procedures in all ways and at all times with respect to any aspect of the data handled or services

rendered in the undertaking of the position; and

Clinical Supervisor, January 2012-August 2012

Coventry Health Care Prior Authorization Department

• Provides oversight and direction to the staff members including staffing,

training, monitoring, and evaluation.

• Perform nurse review audits for quality assurance.

• Reviews the timeliness, appropriateness, and medical necessity of utilization

processes performed by the staff. Prepares reports detailing the monitored

activities.

• Actively participates in the development, implementation, and oversight of the

utilization management activities for the Plan. Serves in an adjunct role for

policy and procedure development and implementation.

• Assists in the identification of issues which may adversely impact the

attainment of department goals (i.e., telephone answer time, talk time,

abandonment rates, etc.)

• Collaborates with other departments to educate providers/vendors and members

regarding participating network providers/specialists, benefits and utilization

management policies and procedures.

• Attends meetings with internal work groups and external business parties.

• Assists in the identification and reporting of potential quality improvement

issues. Responsible for assuring these issues are reported to the Quality

Improvement Department.

• Assists in claim reviews using medical review policies.

Pre-Authorization Coordinator, August 2011-January 2012

Coventry Health Care

• Assure the medical necessity and appropriateness of the delivery of healthcare

resources provided to members as per their benefit package, through medical review of inpatient and outpatient

service requests, utilizing established criteria, clinical judgment, and Medical Director guidelines.

• Utilize established criteria to authorize hospital admissions, diagnostic testing and ambulatory services, etc.

• Assure that members are utilizing contracted providers requested services are

covered benefits, medically necessary, appropriate and of the highest quality.

• Provide oversight of non-clinical staff in the screening of both verbal and written service requests.

• Serves as resource on clinical issues for non-clinical staff to ensure information provided to members and providers is current and accurate.

Health Occupations Teacher, July 2010-Aug 2011

District School Board of Pasco County

• Organize and implement an instructional program based on students’ learning styles for Career and

Technical Education program

• Act as club advisor for HOSA (Health Occupations Students of America) club and Florida Department of Public Health’s SWAT (Students Working Against Tobacco) team

• Collaborate with School’s Bookkeeper for Health Occupations Class’ budget and expenses

Case Manager, Apr 2010-August 2010

Conifer

• Review admission cases in call center environment using InterQual criteria software

• Provide recommendations for admission to various hospitals across the country

Night Clinical Instructor (adjunct position), Nov 2009-Aug 2011

Ultimate Medical Academy

• Implement curriculum for Certified Nursing Assistant/Patient Care Tech Program

• Monitor and supervise CNA/PCT students during externship training at various assisted

living and skilled nursing facilities.

Per Diem Registered Nurse, June 2009-May 2010

Pasco Regional Medical Center

• Assist physicians with procedures such as esophagogastroduodenoscopy, colonoscopy,

Endoscopic Retrogade Cholangiopancreatography, bronchoscopy, and pain management

• Provide patients with conscious sedation

• Provide health education to patients

• Review patient charts

Per Diem Registered Nurse, April 2009-Sept 2009

Gulf and Lake Academy

• Administer medication to juveniles residing in a moderate risk residential

commitment program

• Provide nursing care as needed to juvenile residents

• Perform chart audits for quality assurance

• Generate paperwork needed for residents’ off-site facility medical appointments

Health Occupations Teacher, July 2007-Apr 2010

District School Board of Pasco County

• Organize and implement an instructional program for Career and Technical Education

program

• Act as club advisor for HOSA (Health Occupations Students of America) club and Florida Department of Public Health’s SWAT (Students Working Against Tobacco) team

• Generate report for Florida Department of Education’s SUCCEED grant

• Collaborate with School’s Bookkeeper for Health Academy’s budget and expenses

• Lead the Health Academy’s Committee and Health Advisory Board Council

District Nurse, October 2005-June 2007

Wasco Union School District

• Conduct hearing, vision, height, weight, scoliosis, dental, and acanthosis screenings

• Ensure that immunization status of students is current

• Case manage students with specialized healthcare needs

• Provide services for employee wellness

• Coordinate Medi-Cal Administrative Activities (MAA) program and LEA Medi-Cal

program.

• Organize community events such as health fairs, nutrition classes, and blood drive

• Provide CPR/first aid training to staff and students

• Provide individual health education to students with asthma, diabetes, and other health needs

• Provide group health education in classroom setting

• Perform health assessments for special education department

• Educate special education staff on specialized health care procedures

• Participate in community collaborative meetings, IEPs, Student Success Team

meetings

• Act as resource person for health clerks at each school site.

Utilization Review Nurse/Case Manager, May 2005-October 2005

CHW

• Responsible for operations of Utilization Review Program.

• Responsible for implementation of Utilization/Discharge Plan using InterQual.

• Conduct initial, concurrent, discharge review with insurance care management team.

• Collaborate with members of multidisciplinary team.

• Assist administrator with preparation for JCAHO survey.

District Nurse, July 2003-April 2005

Delano Joint Union High School District

• Conduct hearing, vision, height, weight, acanthosis screenings

• Case manage students with specialized healthcare needs

• Ensure that immunization status of students is current

• Provide services for employee wellness

• Provide CPR/first aid training to staff and students

• Participate in Healthy Families/Medi-cal outreach and time survey

• Provide individual health education to students with asthma, diabetes, and other health needs

• Provide group health education in classroom setting

• Perform health assessments for special education department

• Educate special education staff on specialized health care procedures

• Perform specialized healthcare procedures such as g-tube feedings, trach management,

catheterization as ordered by physician

• Participate in community collaborative meetings, IEPs, Student Success Team meetings

Program Supervisor, March 2001-July 2002

Delano Union School District

• Oversee 3 family advocates and assist with their 30 case managed families

• Coordinate and facilitate multidisciplinary team and committee meetings to ensure that the needs of families are met

• Coordinate programs accessible to the community i.e. Parenting classes, Mommy &

Me, After school Learning Projects

• Coordinate community events for the families and children of Delano

School Nurse, June 2000-March 2001

Delano Union School District

• Case manage students with specialized healthcare needs

• Provide individual health education to students with asthma, diabetes, nutrition and other health needs

• Provide group health education in classroom setting

• Perform specialized healthcare procedures such as g-tube feedings, trach management,

catheterization as ordered by physician

• Conduct immunization clinics, vision, hearing, dental, and scoliosis screenings

• Participate in community events

• Participate in services for employee wellness (i.e. health newsletter, blood pressure,

blood sugar, cholesterol screenings, and tuberculosis skin tests)

• Provide staff education such as CPR/First aid, Blood borne Pathogens, and Child

Abuse

• Participate in Healthy Families/Medic-cal outreach and time survey

Registered Nurse, Endoscopy May 1999-June 2000

Unit, Mercy Hospital

• Facilitate admission and discharge of outpatients and inpatients

• Monitor and provide care for patients undergoing conscious sedation

• Assist doctors in endoscopic procedures such as colonoscopy,

esophagogastroduodenoscopy, liver biopsy, dilation, and ERCPs

• Provide patient education on diseases, treatment, diet, and prevention to patients and

family

Registered Nurse, Level II NICU, Feb.1998-May 1999

Kern Medical Center

• Handle care of 1:1 and 1:2 acuity patients with RDS, Prematurity,

• Hyperbilirubinemia, Feeding Intolerance, R/O Sepsis, Infant of Diabetic Mother

• Facilitate admission and discharge of patients

• Educate parents of their infants’ diseases, treatment, prevention, community

resources

QMRP/Administrator/RN, Sept. 1997-Feb.1998

Loyd’s Liberty Homes

• Responsible for case management of active/nursing treatment services provided to

developmentally disabled clients ages 12-27 years of age residing in Loyd’s Liberty Home facilities

• Direct activities of subordinate staff

• Coordinate individual service plan objectives

• Conduct in-service training to all employees of Loyd’s Liberty Homes

Volunteer Experience

The Skills Center of Tampa-501c3 organization for youth development Website: www.theskillscenter.org

• Coordinate/Facilitate Free-Throw-a-Thon and Sports Banquet for The Skills Center of Tampa, a non-profit organization.

• Coordinate community service project/college visits for The Skills Centerr of Tampa’s girls program.

• Provide outreach calls to potential donors/sponsors for The Skills Center of Tampa.

• Facilitate and ensure ongoing communication with the parents of The Skills Center of Tampa’s Girls program.

• Create video slideshows to feature the girls’ program for the Skills Center of Tampa.

Education and Training

California State University of Bakersfield June 1997

Bachelors's Degree in Nursing

Minor: Psychology

Certifications

Registered Nurse - State of Florida License #9265411 Exp 4/2017

Registered Nurse by Endorsement for the following states: Arizona, Arkansas, California, Colorado, Connecticut, Georgia, Illinois, Massachusetts, Mississippi, Nebraska, Nevada, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Vermont, and Wisconsin

Registered Health Coach-Health Sciences Institute Exp 7/2018

References

Available upon request

Contact this candidate