Utilization Review Nurse

Proven track record of meeting and exceeding standards and deadlines with a high level of accuracy

Challenge-driven professional with comprehensive understanding of assessment, planning, coordinating, implementation and reporting of complex clinical data in support of clinics and programs; 20+ years of experience in the nursing field with core competencies in:

Maintaining Compliance with Regulations Reviewing Patient Records and Progress Effective communication skills

EDUCATION

Licensed Nurse in MD, DC, DE, NJ,NC, SC, and GA

20+ years of experience of solid experience in the nursing field

Howard Community College

2004, Nurse Refresher Course - Certification

Springfield School of Nursing via Howard Community College

LPN Credentials Earned

CERTIFICATIONS

BLS; IV Therapy; Peritoneal Dialysis; Dementia Care; ICD-9DM [ CMS ]

SKILLS

5/2015 – Present COCARE MANAGEMENT, Hollywood, FL

Care Manager

Perform in home assessments [ Medical, Environmental, Emotional]; Medication Reconciliation; Coordinate sources/services based on patient needs, Interact with interdisciplinary team, and document all findings

3/2014 – 5/2015 NPHC STAFFING, Miami, FL

Care Manager

Perform in home assessments [ Medical, Environmental, Emotional]; Medication Reconciliation; Coordinate sources/services based on patient needs, Interact with interdisciplinary team, and document all findings

2/2013 – 5/2013 HEALTHSPRINGS, Baltimore, MD

HEDIS Nurse

Electronically reviewed in-house medical records for all HEDIS measures in accordance with CMMS guidelines. Performed over reads for quality and risk assessment.

9/2012 – 1/2013 AEROTEK, Baltimore, MD

Case Management Telehealth Nurse

Performed phone triage on the patient from the house calls from Nurse Practitioners and Doctors

in the field gathering clinical information, to get the information into the database. This information was used for third party assessments.

4/2005- 12/2011 COMPREHENSIVE NURSING SERVICES, Baltimore, MD

Wound Care Nurse

Visit patients at home for the purpose of providing treatment of wound per physician orders. Measured and documented appearance of wound site(s). Monitor and record any change in patients. Identify medical, psychiatric, and social needs of patients. Communicate issues with all disciplines concerning patient care. Educated patients as to the importance of nutrition to the healing process. Train family members or friends to perform treatments. Communicate with insurance provider concerning progress of patient.

10/2011-12/2011 ALLMED STAFFING, Chicago, IL

Clinical Practice Consultant

Acted as a liaison between UHG and its providers to promote preventive healthcare services for members enrolled in UHG’s Community Health Plan. Collected HEDIS type measures for the HEDIS season.

6/2010 – 10/2010 Medassurant, Columbia, MD

Data Review Consultant

As a worker in Healthcare Informatics responsibilities included research and review of medical records pertaining to Claims Integrity as it relates to chronic diseases for the purpose of correlating and recording ICD-9DM codes as per CMS guidelines

3/2009- 6/2009 Outcomes Inc Norcross, GA

3/2011- 6/2011

HEDIS Chart Review Nurse

Responsibilities include coordinating appointments with advocate for the purpose of on-site field review of medical records, research and review designated records for HEDIS, transmit information via computer to IT department, as well as recording and submitting time card, mileage, and expenses

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