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RN Denials Prevention

Miami, Florida, United States
October 28, 2016

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Maria Riviere, RN

Miami, FL 786-***-****

Case Manager

Compassionate and versatile Case Manager with more than 20 years of experience in healthcare. Proven record of cultivating and sustaining relationships with clinical teams, business partners, and diverse groups of patients and their families. Comprehensive understanding of intake, referral, and discharge procedures. Demonstrated history of integrating cultural sensitivity to provide quality care for patients of all backgrounds. Expertise in crisis intervention, care and treatment planning, case management, and direct patient care. Bilingual in English and Spanish.


Case Management Quality Care Compassionate Nursing Screening and Intake Procedures Clinical Collaboration

Crisis Intervention Discharge Planning Treatment Coordination Referral and Network Management Utilization

Patient Advocacy Supervision Training and Staff Development Interpersonal Communications Cost Controls Cultural Sensitivity Community Outreach and Engagement Safety Standards Regulatory Compliance EXPERIENCES AND ACHIEVEMENTS

BAPTIST HEALTH SOUTH FLORIDA, Miami, FL 9/2005 – 9/2016 ED Case Manager RN – Doctors Hospital 5/2016 – 9/2016 Led care coordination and case management for Emergency Department. Ensured compliance with regulations, industry best practices, and Milliman/Interqual medical criteria. Oversaw admissions processes, conducting comprehensive intakes to determine appropriate level of care.

Cultivated relationships with clinical team members, as well as diverse patient population. Corporate Nurse Auditor 5/2007 – 5/2016

Conducted detailed audits on medical charts, reviewing and analyzing billed claims to ensure appropriate charges and utilization. Led resolution of claims and concerns from insurance providers, patients, internal departments, and regulatory agencies, such as ACHA and OIG. Collaborated with audit team on review and release of claims from Billing Department holds, as well as managed back-end resolution of denials.

Selected to act as liaison and community resource for organization on coding and charge entry concerns.

Earned BHSF Corporate Nurse of the Year Award in 2015. Utilization Management and Discharge Planning Nurse 9/2005 – 5/2007 Oversaw care management for patient group/case load, advocating for patients throughout care within hospital. Ensured optimal utilization of resources, as well as reviewed care plans and service delivery for adherence to best practices, compliance with regulations, and alignment with external review agency guidelines.

Collaborated with interdisciplinary clinical team on patient care from intake through discharge, including leading discharge and referral planning for continued care of illnesses and symptoms. MIAMI CHILDREN’S HOSPITAL, Miami, FL 2/2004 – 9/2005 Clinical Documentation Specialist

Analyzed and reviewed medical records and clinical documentation, ensuring appropriate coding and reimbursement. Monitored documents and claims to ensure effective utilization and that service rendered was appropriate for clinical needs. Measured documents and data against organizational goals and outcomes to identify areas for improvement.

Improved accuracy and completeness of clinical documentation through collaboration with clinical and medical records teams, as well as increased satisfactory QA reviews.

Facilitated training for members of patient care team to ensure consistency and quality of service. Maria Riviere, RN

Resume, Page 2

BLUE CROSS/BLUE SHIELD OF FLORIDA, Miami, FL 2/1995 – 12/2003 Healthcare Auditor 8/2002 – 12/2003

Managed onsite audits for inpatient claims. Ensured compliance with audit procedures and regulations, as well as provided comprehensive reports to internal healthcare teams.

Developed and implemented policies and standards for audits, customized to each line of business and based on provider type to ensure fairness and consistency. Case Manager – Publix Group 3/2001 – 8/2002

Collaborated with leadership teams and group members for Publix throughout the state of Florida. Monitored and resolved catastrophic cases and chronic issues.

Established and sustained relationships with partners for BC/BS Florida PPO, Care Manager, and other traditional products.

Supervisor of Referrals and Care Management Department 2/1999 – 3/2001 Directed daily operations for Referrals team, as well as oversaw internal operations for Care Management department. Recruited, hired, trained, and supervised personnel, including nineteen direct reports.

Evaluated team members for performance, ensuring adherence to metrics and guidelines, as well as providing ongoing coaching and development for growth. ADDITIONAL WORK HISTORY

Retrospective Review and Discharge Planning Nurse, B lue Cross Blue Shield of Florida, Miami, FL Precertification and Utilization Review Coordinator, B lue Cross Blue Shield of Florida, Miami, FL Health Information Referral Coordinator (Managed Care), S outh Miami Hospital, Miami, FL Staff RN (Various Departments), S outh Miami Hospital, Miami, FL Staff Nurse (Med-Surg, Telemetry, and Maternity), C obb General Hospital, Marietta, GA EDUCATION AND CREDENTIALS

Bachelor of Science, N ursing (RN to BSN Program), Chamberlain College of Nursing, In Progress Associate of Science, N ursing, University of West Georgia at Carrollton Registered Nurse (RN), S tates of Florida and Georgia

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