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Jacksonville, FL
October 22, 2018

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Joy Chambers




Professionally trained LPN with experience ensuring high standards culturally competent care for wide variety of patients with diverse needs.

Florida Blue/Blue Cross and Blue Shield

May 2017-October 2018

Applied clinical knowledge and expertise to review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria, while meeting compliance standards and timeframes

Reviewed all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity

Reviewed cases and potential denials with the Medical Directors

Researched requests not clearly meeting established criteria

Assisted the Prior Authorization non-clinical representatives with the Prior Authorization process

Coordinatedand maintain complete written documentation on all prior authorizations requests.

Collaboratedwith other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors.

Answered inbound calls regarding authorizations within established time frame• Documented contact information in electronic medical record system

Maintained productivity

Provided accurate prior authorization information to provider offices

Worked with Medicare and Managed Care including medical review, prior authorization or appeals, with experience utilizing established criteria to make medical review determination

Worked with the following coding systems: ICD-10, CPT-4 and HCPC

Worked with multiple research/processing systems

Worked with MS Word, Excel and PowerPoint

Used utilization management systems and clinical decision making tools such as: Medical Coverage Guidelines (MCG), CMS guidelines, and InterQual

Worked with Florida Blue systems such as: JIVA, Diamond, Quest, Convergence, and Siebel

Quality Review Nurse Team Lead

Florida Blue/Aerotek

January 2015-May 2017

Perform medical chart requests, reviews and abstraction to support HEDIS/STARS

Analyze member/provider records from multiple software programs

Interpret and apply federal and state Medicare policy and regulation pertaining to HEDIS

Audit abstracted data for accuracy and quality assurance

Collaborate with providers to obtain required data for reporting

Responsible for status reporting to management

Conduct Quality Over Reads

Perform SDS abstractions

Oversee and direct 3 contract employees in Hedis Measure Specific roles and Guidelines

Conduct training and education for employees for Hedis

Use Blue Bi, Sharepoint, Availity, Seibel, Diamond, WIT, Altegra Portal, Pims, and knowledge of JIVA to perform job functions and educate team

Medical Review Nurse

Centene Corporation/Sunshine Health

June 2015 – Current (contract)

Review admissions through on-site and telephonic review to ensure medical necessity and appropriate level of care

Review and audit patient charts through on-site hospital visits

Act as clinical resources to referral staff and make appropriate referrals

Provide patient and provider education

Data enters assessments, authorizations and reviews into the system

Utilization Management Pre-Authorization Nurse

Shands/UF Health-First Coast Advantage, LLC.

March 2014- January 2015

Reviewed and authorized procedures, surgeries and office visits per FL Medicaid protocol by reviewing clinical documentation for medical necessity

Worked closely under AHCA and FL Medicaid guidelines in reviewing and documenting all procedures

Worked directly with Medical Directors in determining medical necessity using Interqual Criteria

Used all knowledge in nursing practices in determining and reading clinical documentation in order to ensure that medical necessity and guidelines were used in decision making

Worked independently in decisions and as a team for pre authorization to function and keep company under budget

Use tools such as Click4Care Manager(Epic), Interqual, Provider Portal, FLMMIS, HaMi and Medicaid Handbook and fee schedule each day to perform job duties

Accepted individual tasks or assignment from the FCA, LLC Medical Directors to coordinate and manage care with FCA,LLC Inpatient, Out Patient Case Management Team, and with In Network and Out of Network Providers

Employee Health Nurse

Shands Employee Health

October 2013-January 2014

Interpreted and evaluated the employee’s medical and occupational history, subjective complaints, physical examination, along with lab values or other diagnostic screening test and personal exposure values

Screened, immunized and drew blood work and samples from new Hires, exposure and injured employees

Monitored Workers Compensation injuries

Treated and evaluated all On the job injuries

Maintained and tracked all exposures from all Shands employees

Hospice LPN

Haven Hospice, Orange Park, FL

January 2013 –October 2013

Worked in an interdisciplinary care setting to teach, assist, and support patient/family with the dying process

Monitors patients' medical conditions and provides accurate reports to attending physicians as appropriate and to the patients' RN

Provided full range of hospice nursing care to patients and families in the care center under the supervision of a hospice RN

Unit Manager-SSU/Clinical LPN

Consulate Healthcare, Orange Park, FL

August 2008 -May 2011

Provided care for chronically ill, post/pre surgical patients and medical/surgical patients in sub-acute unit

Provided wound care, respiratory and palliative treatment to patients under physicians orders

Responsible for all medical orders written and verbal as received from physician

Monitored and assessed sub-acute patients from admission to discharge and reported and documented all aspects of care

Educate nursing staff on needs of patients

Managed clinical and support staff in patient care activities while maintaining high level of staff morale and professionalism

Responsible for primary care, case/medication management

Responsible for reporting on all Medicaid/Medicare patients’ medical status and ensuring all documentation was accurate and correct under JHCO and AHCA guidelines

Responsible for weekly reports on Falls, Psychotropic drugs, Medication Totals, and Wounds

Ensure staff was properly educated on patients’ needs and status and all halls were properly staffed at all times.

Attend and reported in all Utilization Management, Care Plan and Admission and Discharge meetings

Charge LPN

Cedar Hills Nursing and Rehab, Jacksonville, FL

June 2006-July 2008

Coordinated with physicians to develop care plans for patients

Acute and chronic patient care from medication to wound care

Treated and evaluated patients from admission to discharge in all aspects of care


LPN Certification

IV Certification

BLS Certification

Enrolled in CPT/Coding Course


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