Registered Nurse Customer Service
Resume:
Natalie Lynne White R.N. C.R.R.N.
Atlantic Beach, Fla. 32233
****************@*****.***
OBJECTIVE: To obtain a position in which my experience and education can be utilized in the most resourceful manner, thus allowing me to demonstrate my abilities to provide for the maintenance of an organization.
SKILLS: Problem solving and critical thinking, organized and analytical, multi-tasking, Medicare Legislative compliance knowledge, clinical and operational auditing, appeals, medical necessity, utilization review, knowledge of ICD-9 and CPT codes, knowledge of billing/reimbursement, claims review and cost containment, knowledge of insurance benefits, authorizations, appeals limitation and coverage issues, Medicare documentation education and training, customer service oriented, case management, discharge planning, marketing and insurance. Knowledge of Interqual Criteria. Word, excel and data entry proficient. Multi computer system use. Report writing capabilities, EMR and all script referrals.
EXPERIENCE:
Aetna Healthcare
April 2013-June 2014
Reason for leaving: (Merger/reorganization layoff)
Case Manager-Medicare
. Complex and Proactive Case Management teaching and educating member on Disease
Management.
. Discharge Planning
. Readmission Risk Management Program (Proactive Case Management)
. Precertification authorization for HHC, infusion, ambulance and procedures.
. Able to use multiple computer systems. Worked in 100% Virtual environment.
. Familiar with NCQA and Medicare guidelines.
. Managed case load of 60 members.
St. Vincent’s Medical Center
January 2013-April 2013
Case Manager-Acute Care
. Evaluate patient for correct status in Acute care. i.e. inpatient, Observation, Day stay to
facilitate proper reimbursement.
. Work with EMR
. Utilization Review (Initial and Continued stay reviews)
. Monitor length of stays by identifying when patients no longer meet criteria for acute
care and facilitate with physicians to discharge patient in a timely manner.
. Have good understanding of the different payor guidelines for acute care.
. Identify avoidable days and delays in testing or treatment.
. Use of Interqual Criteria.
. Identify correct DRG working code.
. Educate and evaluate physician’s on their documentation to maximize reimbursement.
Brooks Rehabilitation Hospital
October 1997 – October 2012
Positions held while employed with Brooks Rehabilitation:
Nurse Liaison
March 2004 – October 2012 (Brooks Rehab)
. Evaluate and assess patients for meeting facility and payor criteria for admission to Brooks Rehabilitation Hospital and Skilled Nursing Unit.
. Worked with EMR
. Coordinate communication between physicians, discharge planner, case manager.social worker, medical staff, patient and caregivers regarding
discharge planning.
. Establish and develop relationships within acute care hospitals, skilled nursing facilities and community by arranging and participating in vendor fairs
and in-services.
. Maintain productivity numbers.
. Talk to external insurance case managers, pre-cert and medical directors as needed regarding patients care, authorization and denials.
. Evaluate and determine other options for high cost medication and services.
. Evaluate whether patient is medically stable for transfer to Rehabilitation.
. Discuss with the patient what to expect while in rehab, the projected length of stay at rehab, benefits and insurance questions and any discharge.
needs the patient may have upon discharge to community i.e. equipment, social issues, continuum of care
Outpatient Utilization Review Manager
July 2003 – March 2004 (Brooks Rehab)
. Medicare resource and clinical auditor/utilization review for 20 outpatient centers.
. Provided ongoing education, training and in-services on Medicare regulations and
changes within the rehab industry. As well as insurance, billing, charging and
documentation training.
. Knowledge of ICD-9 and CPT codes.
. Coordinated several committees including the clinical advisory and outpatient
utilization review committee.
. Assisted billing office with denials and appeals.
. Provided case management for comprehensive pediatrics with traumatic brain and
spinal cord injuries – facilitated monthly team conference and coordinated patient
care, authorizations and benefits.
Clinical Auditor/Corporate Compliance
July 2001 – July 2003(Brooks Rehab)
. Assisted with compliance investigations with the Corporate Compliance Officer
. Operational and Clinical Auditing.
. On due diligence team for new acquisitions.
. Research for Medicare regulatory regulations, practice acts and industry changes.
. Assisted with legal department as needed.
. Medicare resource/consultant for Medicare Probe team.
. Comprehensive report writing for Senior Management and Board of Directors.
. Word, Excel and power point skills.
Sr. Case Manager/Utilization Review
October 1997 – July 2001 (Brooks Rehab)
. Successfully set up and implemented process to end a pre -payment Medicare review.
. Reviewed claim denials for 15 outpatient centers to recover monies by researching, analyzing and drafting letters for appeals/administrative law
hearings.
. Auditor for Medicare Compliance for clinical/billing issues for 15 outpatient centers.
. Provided ongoing education/in-services to 15 outpatient centers on updated Medicare regulations and compliance.
. Supervised three employees in outpatient case management department.
. Provided direct case management services on all outpatient Medicare, commercial,Medicaid, Tricare and Work Comp patients.
. Liaison for all payors regarding reimbursement, insurance benefits, limitations and coverage issues in dealing with authorizations and denials.
Prudential Health
August 1997 – October 1997
On-site Utilization Review Nurse
**Was laid off in merger due to Prudential selling their HMO to Mission Health
. Onsite Utilization Review Nurse @ Baptist Medical Center
. Utilization Review/Discharge Planning
. Used Interqual Criteria
Anthem Health
August 1994 – August 1997
HMO Precertification Nurse August 1994 – December 1994
HMO Senior Coordinator Supervisor January 1995 – July 1996
HMO/PPO Case Manager August 1996 – August 1997
**Was laid off due to Anthem shutting down their healthcare program
. Supervised HMO unit with a membership of 28, 000
. Catastrophic Case Management (transplants, cancer, HIV, CVA, BI, SCI, neonates).
. Strong negotiating skills and cost containment report capabilities
. Quality Assurance (auditing, NCQA preparation)
. Claims review on large case billing
. Attended grievance and claims review committee
. Used Interqual Criteria
**Any job experience prior to 1994 would have been as a Registered Nurse in an acute care hospital and home health care setting (9 years).
Education:
Graduated in 1985 with an Associate in Science Nursing Florida State College Jacksonville
Obtained Registered Nurse license in 1986
Obtained C.R.R.N. 2009 (Certified Registered Rehab Nurse)
BLS CPR Certified
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