Profile

Diversely skilled case manager with focus on clients with complex needs. Adept at multi

tasking, with many community contacts. Possess tenacity and unrelenting ethical integrity. Experience

MULTI ACUITY CASE MANAGER. OPTUM 2011 TO PRESENT

Directing and guiding multi acuity cases following in depth patient assessment. Develop, implement and monitor a comprehensive plan of care with patient, family and clinical team.

UTILIZATION MANAGER. HUMANA. CHARLOTTE, NC 2010 2011 Assess inpatient admissions for accuracy in assignment of patient status in correlation with clinical condition based on Milliman criteria. Initiate actions to obtain appropriate determinations. Support denials management by documenting activities related to denial ajudication according to

UTILIZATION MANAGEMENT. NOVANT HEALTH . CHARLOTTE, NC 2009-2010 Collaborated with physicians and other members of health care team to promote and adhere to regulatory compliance. Coordinated and conducted initial, concurrent and retrospective medical necessity reviews. Utilized Interqual criteria CLINICAL AUDITOR. NOVANT HEALTH. CHARLOTTE, NC .1993-2008 Coordinated and performed concurrent and retrospective review of patient accounts in accordance to hospital guidelines. Performed chart audits to assure accuracy in charging based on medical documentation to ensure correct reimbursement and compliance. Reported and Educated staff for improved practice. Performed appeals of denied claims for commercial payers.

Utilization Management. Church Home Hospital 1985-1990 Staff Nurse. Med surg, peds. St. Joseph. 1979-1984 Staff Nurse. Med surg. Elkins Park 1976-1977

Staff Nurse. Pediatrics. Mt. Washington Pediatrics. 1975-1976 Karen Dougherty

704-***-**** jikar acy7fo@r.postjobfree.com. 617 Infinity Rd. Durham, NC 27712 Education

Maryland General of School of Nursing 1972-1975

Professional References

Mary Beth Yancy RN. 704-***-****

Deb Stamp RN. 269-***-****