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Medical Nurse

Location:
Louisville, Kentucky, United States
Salary:
63000
Posted:
November 29, 2018

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Resume:

Sarah C. Fernkas

***** ******** ***** #***

Louisville, Kentucky 40299

502-***-**** (cell)

E-Mail: ac7trs@r.postjobfree.com

OBJECTIVE:

Diligent Utilization Review Nurse with over 20 years of experience ensuring that members get the appropriate level of medical care. Adept at efficiently allocating medical resources while ensuring that each member is treated fairly. Specialize in finding a balance between the fiscal needs of company and the care needs of every patient.

QUALIFICATIONS:

Licensed Practical Nurse since February 1998. Strong leadership skills in a variety of healthcare settings. Knowledgeable, precise and focused on the quality of healthcare provided to patients.

EDUCATION:

1996-1998: Kentucky Tech-Jefferson Campus

Diploma from Practical Nurse program

1993-1996: Jefferson Community College

Undergraduate studies

EMPLOYMENT:

September 2017- Present

Central State Hospital

Lead Utilization Review Nurse

Provides the leadership and direction for the Utilization Review Functions including,

Program admission and review in accordance of all patients in accordance of laws and statutes.

Ensures appropriate discharge procedures.

Coordinates the review process within the framework of other monitoring activities.

Continuous review of process procedures for improvement.

Data collection and analysis followed with education of the team.

Work directly with external reviewers and agencies at the state and federal level.

Manages patient care to ensure it is within the treatment plan.

Documents the process through transcription orders, treatments provided and participates in the overall medical plan.

Cross train with Medical Clinic and Employee Health and Infection Prevention.

February 2010- September 2017

Humana – Louisville, KY

Utilization Review Nurse – Clinical Advisor- Medicare

Responsible for precertification of inpatient skilled nursing care admissions based on medical necessity, appropriateness, CMS guidelines, MCG guidelines and confidence of my nursing judgement. Daily, I must collaborate with providers in obtaining the desired information in a timely manner. Also, need to identify any services not warranted for skilled care and recommend alternate level of care for that member. If provider declines, correspond to our Regional Medical Director for review.

January 2008- February 2010

Humana - Louisville, KY

Nurse Clinical Advisor - Commercial

Responsible for precertification of acute inpatient admissions, outpatient medical procedures, home health and durable medical equipment based on medical necessity, appropriateness, specific company guidelines and nursing judgement. Primary nurse over mental health inpatient admissions for the UK HMO network and HumanaOne.

March 2006- December 2007

Curascript Infusion Pharmacy

Financial Case Manager

Responsible for obtaining precertification from various commercial insurance companies for Infusion services.

2005- 2006:

Visiting Nurse Association

Central Intake Coordinator-LPN

Responsible for the processing of patient referrals and verbal orders; explains VNA services to referring sources, patients, and potential clients; receives telephone referrals; works with insurance Case Managers; provides backup for other staff in the department to facilitate the operation of an efficient, productive department.

2004-June 8th, 2005: Laid off due to selling and consolidation of company.

Spectracare, Inc

Financial Case Manager-LPN

Responsible for obtaining precertification from various commercial insurance companies for home health and infusion companies.

Utilization Case Manager-LPN

Utilization review for home health and infusion services.

2001-April 16th, 2004: Laid off due to selling and consolidation of company.

National Health Services

Medical/Claims Review Nurse

Responsible for precertification of inpatient/outpatient medical procedures and durable medical equipment based on medical necessity, appropriateness, specific company guidelines and nursing judgement.

Conducts medical review of claims for appropriateness and medical necessity by reviewing primary diagnosis, precertification cases, clinical history and using nursing judgement.

2000-2001:

Jewish Hospital

Payor Specialist-LPN

Collaborate with outcomes/care manager to provide specific clinical information to third party payors. Responsible for timely provision/flow of specific clinical information to third party payors to ensure certification/approval of inpatient and post discharge services.

1999-2000:

Central State Hospital

Patient care nurse-LPN

Direct patient care and medication administration for psychologically impaired patients with substance abuse problems.



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