RN Case Manager

SUMMARY OF CLINICAL SKILLS:

To secure a position as an RN Care Coordinator in a challenging environment, where I can utilize the skills and experience obtained as a highly trained RN case manager.

EDUCATION:

May 2006 Salem State College Salem, MA

Bachelor of Science in Nursing, Minor in Psychology

WORK EXPERIENCE:

6/2015-Present Neighborhood Health Plan

Onsite RN Case Manager Boston, MA

Facilitate transition of care from acute inpatient setting to the next most appropriate level of care (e.g., rehabilitation, skilled nursing facility and home care) utilizing Interqual Criteria.

Enhance collaboration between the facility and NHP care managers by conducting concurrent review.

Increase accessibility to social, behavioral health and disease management programs, as well as to Community Medical Alliance (CMA) by referring identified high risk members to specific disease programs.

Develop and maintain collaborative, proactive and patient focused relationships to maximize client health care outcomes.

Serve as a member advocate and advise facility care managers of member’s covered benefits (Commercial and Medicaid).

Build collaborative working relationships with hospital/ Provider partner staff, including participating in regularly scheduled site visits to promote NHP care management programs.

Communicate effectively with NHP Medical Directors to obtain authorization for cases not meeting Interqual Criteria Guidelines and participate in weekly rounds discussions and on case by case basis.

9/2014-5/2015 United Health Group

RN Field Case Manager Waltham, MA

Responsible for conducting initial and follow-up assessments within designated timeframes on members identified as having high risk complex case management needs (assessment areas include: clinical, behavioral, social, environmental and financial).

Engage member, family, caregivers, and healthcare providers to assure that a well-coordinated treatment plan is established.

Prioritize member’s care needs, set goals and develop a plan of care addressing gaps and/or barriers to care by use of evidence-based practice as the foundation.

Initiate face to face and telephonic visits when key gaps are identified that require additional nursing follow-up (i.e. post hospital assessments).

Coordinate acquisition and proper use of DME on an ongoing basis.

Collaborate with the attending physicians and Medical Director to revise treatment plans as needed

Document assessments, interventions, and follow-up on disease management activities in Care One system.

6/2013-9/2014 Steward Healthcare Network

RN Care Manager-Tufts Medicare Preferred Dedham, MA

Coordination, Planning, Monitoring and Evaluation. Ensure the appropriate delivery of services through Assessment and Case Identification.

Collaborate with network’s physicians to provide quality focused cost-effective interventions to all clients across the continuum of care.

Establish relationships with clients and their families as needed to determine and facilitate the provision of services.

Develop criteria to identify ambulatory clients at risk for high cost/chronic care and intervenes to provide a care plan, which utilizes appropriate resources across the continuum.

Perform utilization reviews per Interqual Guidelines.

Participate in Case Management meetings and educational programs sponsored by Steward Health Care Network Services (SHCN), Steward Hospitals, and health plans.

Review reports from SHCN & Health Plans to identify claims/authorization issues for reconciliation and determine cost effectiveness.

9/2010-5/2013 Tufts Health Plan

Commercial Onsite RN Case Manager Watertown, MA

Possess knowledge and experience in balancing the quality with the cost effectiveness of specific case management interventions within the Commercial product population.

Able to manage multiple cases in a flexible and professional manner in order to meet the needs of both internal and external customers.

Communicate effectively with THP Medical Directors to obtain authorization for cases not meeting Interqual Criteria Guidelines and participate in rounds discussions.

Proficient in the use of CCMS, TAHP, ALUI, MACESS, Lotus Notes and Excel formatted reports necessary to complete a daily caseload.

Actively participate in department initiatives such as: IR interqual project and assist with writing of an Electronic Review workflow.

Utilize clinical experience and judgment in referring high risk members to SCM for specific disease management post discharge from hospitals.

11/2008-9/2010 Mount Auburn Independent Physician’s Association

RN Case Manager/Telemetry and MICU Cambridge, MA

Responsible for a daily census of 20-25 patients; Initiate a CM assessment for developing an effective discharge plan.

Work collaboratively with members of the patient care team by attending multidisciplinary rounds to discuss cases.

Maintain communication with commercial insurance payers, managed Medicare and Medicaid sources and conduct daily clinical updates to insurance companies.

Work collaboratively with on-site insurance case managers, screeners and other representative of payers.

Involve patient and family in the development of the discharge plan by discussing appropriate discharge options and encouraging active participation in all aspects of discharge planning.

Identify barriers to efficient, cost effective provision of care by facilitation of timely discharges to SNF’s and setting up home services.

Document all pertinent case management activity, assessments, plans, and conversations with patients and families in Meditech and medical record.

Proficient with use of Interqual criteria to assess Severity of Illness and Intensity of Service and review complicated cases with Physician Advisors.

Responsible for issuing Hospital Notices of Non-Coverage when appropriate.

11/2007-11/2008 Lahey Clinic Medical Center Burlington, MA

Staff Nurse-Medical Neurology/Cardiology Unit

Duties and responsibilities include but are not limited to: Assessment, planning, administration of care and evaluation of patients with neurological disorders and cardiac illnesses who require telemetry monitoring.

Delegate work appropriately and provide direction and guidance to support personnel.

Collaborate with patient and family regarding discharge plans.

Demonstrate knowledge and safety while administering high alert medications such as Heparin, Diltiazem and Insulin drips per protocol.

3/2007-11/2007 Whidden Memorial Hospital

Medical/Surgical Float Staff Nurse Everett, MA

Medical/Surgical Unit, Telemetry and TCU

Provided patient care to patients and their families in multiple settings within a hospital.

Duties and responsibilities included but are not limited to: Assessment, planning, administration of care and evaluation of patients in the Medical/telemetry, Medical/surgical and TCU.

Administer I.V. push medications, I.V. Antibiotics, TPN, SC and IM injections.

Provided necessary teaching to patients and families regarding medication regimen and facilitate discharge planning.

Provided care for pre-op and post-op patients in a safe atmosphere.

8/2006-3/2007 Hebrew Rehabilitation Center for the Aged Roslindale, MA

Staff Nurse-Medical Acute Care Unit (MACU)

Daily duties include: assessment, planning, implementation, evaluation and analytical thinking necessary to care for a group of patients with respiratory and cardiovascular complications.

Provide care for patients following a prolonged hospital stay; set priorities for their rehabilitation, along with other interdisciplinary team members.

Closely monitor and provide nursing care for mechanically ventilated patients in the process of weaning from the ventilator, including endotracheal and oral suctioning.

Administer I.V. Antibiotics, I.V. push medications, TPN, tube feedings, monitor chest tube integrity and drainage.

SPECIAL SKILLS:

Bi-lingual: Russian and English.

Telemetry Certified 2007, MCAP and Interqual Proficient.

Working on obtaining CCM certification 12/2016.

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