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Case Manager Care

Location:
Youngsville, Louisiana, United States
Salary:
50,000
Posted:
October 07, 2016

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Holly Best, R.N.

*** ********** ***** **:337 *** ****

Lafayette, La 70508 acwyna@r.postjobfree.com

OBJECTIVE/SKILLS

●Strong Experience in Case Management and Utilization Review for past 8 years, Prior

●Authorizations, Concurrent Reviews, Medicaid, Medicare, Managed Care Insurance and Insurance denials. Have worked with Interqual and Milliman tools.

●Hospital Admissions, Discharge Planning

EXPERIENCE

RN Onsite Clinical Advisor Humana Inc, Jan 2015/Feb 2016

●Duties include Onsite Face to Face with all Humana Members during Acute stay

●Discussed all Humana programs with Members. Answered questions re: MAP.

●Discussed denial of services when member did not meet criteria for IP, LTACH, SNF

●Discussed with Case Managers peer to peer process after denial of service

●Discussed with Patient and Families how to appeal denials using Grievance/Appeal

●UR every two days for Acute, every 7 days for SNF and LTACH

●Observation vs Inpatient UR upon admission to Acute Facility

●Authorization by this RN for SNF

●Routing all requests for services to RMD when not meeting MCG

Sept 2014 to Dec 2014 Family care of Mother in Pittsburgh, Pa with new onset Dementia

RN Case Manager St Joseph Hospice June 2014/ Sept 2014

Duties include: making initial nursing evaluation in determining eligibility for hospice services during visit within 48 hours of referral.

Initiate and coordinate the plan of care. Documents problems, appropriate goals, interventions, and patient/family response to hospice care. Collaborate with the patient/family, attending physicians and other member of the IDG in providing patient and family care on a daily basis.

Instruct and supervise patient/family in self-care techniques when appropriate

Maintain accurate and relevant clinical notes regarding the patient’s condition. Report patient condition and any identified needs/issues to Administrator on daily basis.

Perform supervisory visits with the aide present per state regulations.

Perform Recertification, 60 and 90 day periods.

Participate in IDG meetings every 14 days.

RN Case Manager/Team Leader Louisiana Hospice and Palliative Care Sept 2013/ May2014

●Duties include: making initial nursing evaluation in determining eligibility for hospice services during visit within 48 hours of referral.

●Initiate and coordinate the plan of care. Documents problems, appropriate goals, interventions, and patient/family response to hospice care. Collaborate with the patient/family, attending physicians and other member of the IDG in providing patient and family care on a daily basis.

●Instruct and supervise patient/family in self- care techniques when appropriate

●Maintain accurate and relevant clinical notes regarding the patient’s condition. Report patient condition and any identified needs/issues to Administrator on daily basis.

●Perform supervisory visits with the aide present per state regulations.

●Perform Recertification, 60 and 90 day periods.

●Participate in IDG meetings every 14 days.

RN Case Manager for Fara Health Care/Workers Compensation 2012-2013

●Duties included reviewing all Workman’s Comp requests from Louisiana Workers Comp MDs.

Approval of DME,Surgery,,Physical and Occupational Therapy, Psych Services while following Louisiana Medical Guidelines for Workers Comp. Compilation of pertinent records when sending requests for Medical Records. Laid off with many others after company was bought out by York.

Case Manager 2010 October 2011 LTAC of Louisiana Long Term Acute Care

●Case Manager of 22 bed LTAC, duties include assessing Patient physical, psycho/social needs on admission and continually updating care plans with all members of the health care team. Offering counseling to patient and family while teaching them to cope with complicated situations.

●Communicates with other case managers, Social workers, health professionals and coordinators with regard to patients’ situation.

●Medicare/Medicaid Patients

●Experienced discharges/admissions.

●Quality Improvement data collection monthly and quarterly.

●Commended by DON and CEO frequently for job well done.

●My position consistently ranked in the 90th percentile on patient surveys post discharge.

●Facility closed due to low level of admissions at rural Hospital

Case Manager 2006 2010 Lafayette General Med Center

Case Manager for medical surgical 30 bed unit.

●Medical Assessment on admissions and every 3 rd day during inpatient stay.

●Interqual/Milliman program experience

●Psycho/social assessments, working with MD’s and interdisciplinary teams

●Discharge planning for each admission and discharge using Interqual,

Arrange OP dialysis, NH transfers, LTAC transfers and hospice evaluations.

●Trouble shooting and solving the myriad of med/psych/social issues that arise daily for patients and their Families.

EDUCATION

May 1998 Community College of Beaver County Monaca, PA Associate Degree Nursing June 1992 Paralegal Certification, Penn State University

AWARDS

●Faculty Award for Outstanding Clinical Performance May, 1998

●Selected by fellow nursing students to speak at graduation ceremony

●National Who’s Who in Nursing 1997 1998

●Dean’s List 1997 1998



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