Customer Service Medical
Resume:
Chemberli D. Cline
Stone Mountain, Georgia 30038
*********@*****.***
Summary
To acquire a position within your company that will allow me to utilize my Healthcare
Administration and nursing skills and with proven performance afford me a career with
growth opportunities.
Centene Corporation-Nursewise/Nurse Response Division
Outbound Services LPN
November 11, 2013-present
• Under the direction of a Registered Nurse perform health risk screenings; provide
scripted health education to callers; participate in other health-related telephonic
programs
• Identify actual or potential health or safety needs in callers and facilitates intervention for
prompt resolution
• Document all call-related transactions according to department policies and procedures
• Maintain standards of professional verbal and written communication
• Work effectively with coworkers to maintain and improve operations
• Comply with Federal and respective state’s laws regulating health management
• Participate in organizational process improvement and quality improvement activities
• Submit Medical information into multiple company databases
• Medical Triage
• Customer Service facilitator
Ashford University full-time student
August 3, 2012- August 5, 2013
Masters of Arts in Health Care Administration
Judge Group-Recruiting Agency
Temp Prior Authorization Coordinator for Coventry Healthcare in Atlanta
April 16, 2012-August 3, 2012
Assists with the orientation of providers to the Plan's authorization and review
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procedures and work closely with participating physicians to secure information necessary
for utilization management.
Implements and documents utilization management activities, which incorporate a
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thorough understanding of clinical knowledge and appropriateness of medical services
related to effective cost containment.
Assures the medical necessity and appropriateness of the delivery of healthcare
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resources provided to
members as per their benefit package, through medical review of inpatient and
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outpatient service
Requests, utilizing established criteria, Interqual, clinical judgment, and Medical
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Director Guidelines.
Actively participates in the negotiation and notification processes that result from
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the medical record
Reviews with the facilities. Prepares notification letters of denied and negotiated
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days within the
Established time frames.
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Offers safe, effective alternatives to the inpatient setting for those patients
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requiring interventions prior to their hospitalization. Actively negotiates transitional levels
of care when services requested do not meet acute care criteria.
Utilized established criteria to authorize hospital admissions, diagnostic testing
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and ambulatory care services
Assures that members are utilizing contracted providers requested services are
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covered benefits, medically necessary, appropriate and of the highest quality.
Provides oversight of non-clinical staff in the screening of both verbal and written
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service requests.
Serves as resource on clinical issues for non-clinical staff to ensure information
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provided to members and providers is current and accurate.
Provides accurate, comprehensive, and pertinent utilization data and information.
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Assists in the identification and reporting of potential quality improvement issues.
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Responsible for assuring reports are sent to Quality Improvement department.
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Total Therapeutic Management
Hedis Nurse Abstractor- February 16, 2012 –April 2, 2012
• Hedis Medical Research
• Chart Abstraction
• Chart Reviews
• Commercial Insurance Chart Reviews and Abstraction
• Medical information pursuit
•Data Entry
Emdeon/Chamberlin Edmonds
Precertifcation Nurse Specialist- Sept 6, 2011-February 2, 2012
Write medical cases on a daily basis to submit to Medicaid for retrospective
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payment on behalf of the patient and hospitals.
Retrieve medical information from patient’s charts to submit to Georgia Medial
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Care Foundation for approval of medical claims
Update medical decisions into Pace system daily
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Use Interqual to meet the criteria for patients medical care stay
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Send account reports to team lead weekly
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Correspond with referral coordinates with Medicaid to petition and advocate for
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approval of care on behalf of the Medicaid recipients and medical facilities.
Knowledge of Medicaid rules and regulations set by Department of Community
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Health of Georgia
Knowledge of rules, regulations and policies set by Georgia Medical Care
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Foundation
Patient and Healthcare Facility Advocate
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Alliant Healthcare/ GMCF
Nurse Reviewer-September 2006-Sept 2011
• Perform reviews of provider prior approval/precertification requests.
• Perform other non-prior approval reviews such as prepayment and validation reviews
• Use Interqual books and database to review precertification cases submitted by medical
providers to verify if patient’s stay meets standard for in patient or outpatient stay
• Document the rationale for all review decisions using appropriate criteria
• Evaluates initial clinical information and approve cases that meet criteria
• Refer cases that do not meet criteria and cannot be approved by nursing judgment to a
Referral Nurse Coordinator
• Provide customer service to providers calling via telephone
• Retrospective Reviews/Practioner Office Visit reviews
• Maintain confidentiality of review information and medical records in accordance with
HIPPA compliance
Oakhurst Medical Center Inc. – March 1999-May 2008
Lead LPN/Nurse Manager/Perinatal Case Manager
• Community Health Nurse
• Provided skilled nursing to clients in an ambulatory care setting
• Supervised a team of eight medical assistants and 1 LPN
• Triaged patients in office and via telephone daily
• Referral Coordination/patient prescription assistance coordination/JCAHO coordination
• Disease and Perinatal case management
• Disease management teaching
• Performed various back office duties, phlebotomy, IV therapy, immunizations, ekg and
medication administration
• Assist physicians with various procedures
• Wound care management
• Utilization Review
• Reviewed and audited Charts
• Worked as Family Practice, Pediatric and OB/GYN nurse daily
• Research with treatment of patients with high cholesterol
• Maintenance of vaccine, medications and flu vaccine log
• Coordination and supervision of health fairs throughout the DeKalb and Metropolitan
area
• Diabetic and nutrition teaching
• Patient Care Advocate
• Training of any new employees
Newton General Hospital- August 2003-June 2005
Staff LPN
• Provided skilled nursing care to patients in an acute care setting.
• Worked with adults and pediatric patients
• Performed skilled care to patients according to doctors orders
• Phlebotomy, medication administration, wound care, accuchecks and IV therapy
• Documented confidential and accurate information into data base
• Patient teaching
• MD order transcription
• Supported RN and Physicians whenever necessary
• Worked as Med/Surg nurse
• Chart reviews and audits
Education and Training
Dekalb Technical Institute
Clarkston, Georgia
Licensed Practical Nurse Diploma Hours
800 Theory Hours
800 Clinical hours
March 1995-1996
Ashford University
Clinton, Iowa
Bachelors of Arts Degree in Healthcare Administration
Nov 2008- August 15, 2011
Masters of Arts Degree in Healthcare Administration
Jan 17 2012- August 5 2013
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