Objective

Self-motivated, responsible individual with strong interpersonal and communication skills. Possess extensive medical experience, strong management skills and professionalism. Seeking long-term employment. I would like to have the opportunity to use my advanced skill sets and experience in a position with room for advancement.

Qualifications

Registered Nurse since 1991 and I am currently licensed in the state of Tennessee with various backgrounds (Labor & Delivery, Long Term Care, Mental Health, Home Health, Case Management). I am certified by the NHA National Healthcare Association as a Certified Billing and Coding Specialist eg CBCS. I have worked with BCBST the longest stent of 16 years, in the private and government side of business. I have many strong skill sets that I believe would be an asset to your company. I am proficient in coding, Risk Management / Risk Adjustment, MSD-HCC, Hedis, Utilization Review, Policies and Procedures, Quality Reviews, as well as Auditing and Continuing Education.

Experience

September 2016 – November 2017 Home Care Solutions

Clinical Manager – Team Leader Ooltewah Tennessee

Supervisor of Nursing staff, Physical therapy,Occupational therapy, Speech Therapy. Verified and approved all physician orders and Plan of Care with appropriate diagnosis and skilled need and medically necessary/appropriate 485 or plan of care. Conducted IDT Meeting every week with staff updates and minutes. Responsible for the continued education for all staff/ disciplines as it pertains to Home Health and CMS Guidelines. Did monthly quality review of documentation from all disciplines. Re-educate staff when appropriate assuring all clinicians have appropriate tools to suceed.

March 2016-September 2016 Consulate Health Care

Unit Manager / ADON

Unit manager to Consulate Health Care. Manage clinical nursing staff on a daily basis. Monitor anticoagulant therapy and labs per state and federal guidelines. Monitor antibiotic therapy and infection control.

Handle grievances involving clinical staff. Monitor CQI/QA Charting. Handle issues involving families. Careplan committee. Monitor Falls and returns to the hospital. Work closely with admissions for approval

for admissions and appropriate placement for clients. Have a mixed population of clients, Long Term Care, Skilled Care,Rehabilitation,Palliative Care as well as Respite Care. Work closely with all aspects of pt care from dietary to therapies (PT/OT/ST), memory care as well as dementia and Alzheimer's.

February 2016-July 2016 HEARTH HOSPICE

Chattanooga TN

Case Manager-RN

Admissions to Hospice Care. Working with patients and family caring for terminal or end of life. Palliative care. Pt and Family education and building rapport and fostering emotional support for the patients and family. Work closely with Doctors, Practitioners, Pharmacist and Nursing peers. Offered continuity of care and compassion and empathy. Critical thinking skills and knowledge of dying process and educating the families and patients.

October 2015 - February 2016 NHC HOMECARE

Shallowford RD

Case Manager-RN/ CQI

•Responsible for all Oasis Assessments for the intermittent line of business.

•Do all recertification’s; resumptions of care; verbal start of care.

•Do weekly QA reviews in compliance with CQI- do re-education.

•Work closely with area Wound Care Centers and doctors and nurses of clinics. Excellent pt rapport.

NHC HomeCare Case Manager - Registered Nurse / RN is directly responsible for clinical activities of office staff. Registered Nurse - RN will be part of a team that plans, implements and evaluates patients' plans of care. Our services included IVIG, Wound Vac, Wound Care, Education Diabetes Management, Orthopedics, Elderly Care-Med Plans-anti-coagulation therapy, LVAD .

Responsibilities and Duties of a NHC Case Manager Include:

•Enforces and demonstrates 100% compliance with all Federal, State and local regulations

•Assesses and supervises the delivery of home care services by field staff

•Provides in-home supervision of home care cases.

•Updates care plans as necessary during supervisory visits

June 2014 PRN to Full Time March 2015 Clinical Supervisor Maxim Health Care Svc’s 6142 Shallowford Road Chattanooga TN

Assists with orienting and training Maxim employees

Responsible for all Oasis Assessments for the intermittent line of business.

Do all recertification’s; resumptions of care; verbal start of care.

Directly manage 5 RN’s and 2 Lpn’s.

Do weekly QA reviews in compliance with CQI- do re-education.

Work closely with area Wound Care Centers and doctors and nurses of clinics. Excellent pt rapport.

Maxim Healthcare Services Clinical Supervisor - Registered Nurse / RN is directly responsible for clinical activities of office staff. The Clinical Supervisor - Registered Nurse - RN will be part of a team that plans, implements and evaluates patients' plans of care. This is a brand new line of business I was fortunate enough to get in on. Intermittent care ie. IVIG, Wound Vac, Wound Care, Education. Responsibilities and Duties of a Maxim Clinical Supervisor Include:

Enforces and demonstrates 100% compliance with all Federal, State and local regulations

Assesses and supervises the delivery of home care services by field staff

Provides in-home supervision of home care cases.

Updates care plans as necessary during supervisory visits

September 2014 to November 2014 St. Barnabas @ Siskin Rehabilitation

1 Siskin Plaza, Chattanooga TN

Admissions Nurse for either Physical Rehabilitation or Long Term Care

Admit pt’s with a full head to toe physical assessment, (including skin assessment for decubitis and any skin breakdown) assess level of care needed, Transcribe physician orders from transferring facility and call and verify them with the covering physician. Set up delivery of new medication orders with the pharmacy. Hand off patient to receiving nurse and give them a full comprehensive report. Give flu-shots to consenting long-term patients and employees. Chart Review as needed.

June 2014 to Present (PRN) Maxim Health Care Svc’s

Shallowford Road Chattanooga TN

Long-Term Care Nurse who provides care for patients in their home. Pediatric and Adult care. Administration of medication, g-tubes/feeding tubes, respirators, trach’s and clinical judgment that requires a seasoned and versatile RN.

March 2013 to November 2013 Delta-T-Group-(Independent-contractor)

Moccasin Bend Mental Health Institute

Admissions nurse for Intensive Inpatient Program. Detailed medical and mental health history. Comprehensive medical and mental, physical evaluations. Administer medications as written per doctor’s orders. Work in the capacity of charge nurse as needed. Daily care and concurrent review and documentation for CQI and continuity of care.

August 2012 to February 2013 Bradford Health Services

Shallowford Rd Chattanooga TN

Admissions Nurse for the Intensive Outpatient Program. Responsibilities included full medical history and current medical assessment. History of mental illness and or drug abuse. Perform urine drug screens and TB skin tests as well as reading, reporting and certifying results. Implemented new Vivitrol program, one of the first in the Chattanooga area.

February 2012 to PRN Broadpath Healthcare Solution. (travel nursing)

Medical Review Nurse determining eligibility of home health claims By using CMS (Centers for Medicare and Medicaid) guidelines. CMS has established Home Health hierarchy guidelines to determine eligibility and or denial of charges. For these comprehensive reviews you would look at documents submitted by the provider for Oasis evaluation, Certification, Orders, Exclusions, Homebound status, Intermittent Skilled nurse services vs skilled services with no ending indicated and Medical Necessity of all services.

March 2011 to May 2012 Virginia College School of Business and Health & Miller-Motte Technical College

Instructor of Medical Assistants, Billing and Coders. Implementation of curriculum and educational programs for students within the program. Communicate class content to students so that learning occurs and skills are developed. Once skills are developed then students become motivated to learn and achieve their educational objectives.

January 2007 to August 2009 BCBST BlueCross BlueShield of TN

RAPS Nurse Coordinator

The purpose of this position is to coordinate and monitor the risk adjustment data (RAPS) for submission to the Centers for Medicare and Medicaid Services (CMS) and to perform comprehensive reviews of medical records information to support risk adjustment data submission. Audits include retrospective audits and may be performed in house or on site for HCC’s. Must produce clear and concise reports of audit findings and recommendations for upper management.

*This was a brand new department that I got to start up from the very infancy stages. I was able to write policies and procedures and get those implemented. This department has grown from 1 nurse to 3 full time nurses, 2 part time nurses, 1 coder, 1 support tech.

August 2003 to January 2007 BCBST

Principal Health Underwriter/ Supervisor

This position is responsible for the supervision of the Individual Health Underwriting Technicians (3) a Misrepresentation Technician, and Misrepresentation Health Underwriters (4).

Developed Standards to document and maintain procedures; establish new procedures as necessary and effectively communicate these changes to staff. Create and maintain production reports necessary to support performance standards for the positions and assist with production in times of substantial volume and / or staffing shortages.

Misrepresentation Underwriters: Documented and maintained procedures for Misrepresentation. Created and maintained production reports necessary to support performance standards. Perform random audits Misrepresentation leads to ensure appropriateness of the leads that are being pursued. Revue Misrepresentation write ups and coordinate with Legal as necessary ; maintain documentation of write up reviews as an audit of Misrepresentation Underwriter.

Other: Worked directly with Legal on Misrepresentation Cases. Respond to all DOI / TDCI complaints, review and respond to all Member Grievances that deal with Misrepresentation or Individual Health Underwriting, consult via telephone with frustrated customer /members regarding Misrepresentation decisions, assist with Special Projects as needed, acted as area clinical expert, conduct one on ones with my direct reports with documentation of topics discussed both negative and positive. Review audit results with direct reports, review production results, organize staff meetings, train new hires for Misrepresentations, Underwriter and Technician positions.

**UNDERWRITER OF THE YEAR 2004**

November 2001 to August 2003 BCBST

SR Health Underwriter

This position is responsible for medically underwriting applications for individual coverage for the product / contract/ benefits. Developed policies and procedures for the Underwriting and Misrepresentation Department. Perform Quality reviews for Underwriting Staff. Develop and Implement Misrepresentation Department to include working with legal and claims for collections of money.

December 1999 to November 2001 BCBST

SR Coding Analyst

This position is responsible for the research, analysis, recommendation, implementation, problem resolution, maintenance and coordination for anesthesia, surgery, radiology, labs, evaluation and management, diagnostic, therapeutic, home health, home infusion therapy, durable medical equipment, orthotics, prosthetics, transportation, dental, vision, hearing, pharmacy, behavioral health, inpatient/outpatient/acute care, ambulatory surgery, rehab, skilled nursing facility, Hospice Services. This position is also responsible for developing coding policy and procedures in accordance with industry standard coding conventions and specialized coding to support provider billing, contracting (including benefits), adjudication, and reporting efforts

August 1998 to December 1999 BCBST

Nursing Coordinator Specialty Services-Clinical Code Editing & Coding

This position is responsible for direct supervision of 4 registered nurses and 3 senior coding technicians. Directly responsible for all quality reviews. Coordination of Internal and External Provider Audits, maintaining working relationships with other areas of the company including- Medical Policy, Claims Processing, Customer Service, Business Engineering.

December 1995 to August 1998 BCBST

Code Review Nurse

This position was responsible for reviewing predeterminations for Experimental and Investigation, Cosmetic, and Medical Necessity. Reviewed all surgical claims with system edits concerning adjudication. Worked with BEG and Medical Director directly about system edits and adjudication of codes according to the National Coding Initiative. Helped Coordinate the release of new codes each year, ICD-9, CPT, and HCPCS. Performed Quality Reviews. Did Special Projects as needed by manager.

1991 to 1998 Hutcheson Medical Center Ft Oglethorpe, GA

Labor & Delivery:

Cross trained for MED/SURG, OB/GYN and Nursery. Surgical assistant and circulator for all OB/GYN cases done at Women’s Center. Chart Auditor for the entire Women’s Center for QA (Quality Assurance), then the implementation of CQI (Continuous Quality Improvement), served on Career Ladder Council.

Assisted in writing protocols, policies, and procedures for Labor and Delivery.

Charge Nurse after1 years of experience.

January 96 to Nov 98 stayed in PRN pool for Labor and Delivery

Education

Chattanooga State Technical Community College

A.S. Nursing 1991 (continuing Ed)

Registered Nurse 1991 Licensed in TN and GA

2 yrs college level computer training

Certified and Registered Dental Assistant 1986 CSTCC

Personal / Interests

FAMILY, COOKING, GARDENING, HERBS, SWIMMING, CHURCH FUNCTIONS, WATCHING OUR TWIN SONS PLAYING BALL

References

AVAILABLE UPON REQUEST

Contact this candidate