**** * **** ******* **** Unit *, Orlando, FL *****

860-***-****

ad2qg0@r.postjobfree.com

CHANDRA HOLLENS

OBJECTIVE

A dedicated and well-versed nurse, seeking a position to provide and uphold the highest standard of care and customer service.

PROFESSIONAL SUMMARY

Chandra brings 14 years of experience as a multi-Licensed Practical Nurse in the states of Florida, Massachusetts, and Connecticut

Has 5 years of experience as a Utilization Review Nurse, submitting prior authorization requests to insurance companies via portal, fax, and phone

Received authorization requests from providers, processed reviews based on clinical information, policy, and medical necessity

Processed denial letters and appeals for approval

Has worked with chronic conditions such as diabetes, wounds, CHF, COPD, HIV, hypertension, myocardial infarction, cerebrovascular accidents, hyperlipidemia, dementia, Alzheimer’s, psychiatric issues, tracheostomies, gastrointestinal tubes, Jackson Pratt drains, wound vacs, multi-layer leg compressions, amputation, and post operation

Proficient with systems such as: Microsoft Office, Outlook, Access, Allscripts, Mckesson Decision Management, SNAP, Point Click, Epic, TruCare, Faxcom, InterQual, ICD 9 and 10 coding, ICare Path, PEGA, and Xceyls

EXPERIENCE

CENTENE CORPORATION, ORLANDO FL

06/2021 - Present

Medicare Appeals Review Nurse (Wellcare)

Reviewed charts in ICare Path and PEGA systems, utilized various vendors to process overturns and denials

Collected appropriate clinical information from providers, made determination of medical necessity based on Medicare guidelines

Complied with authorization timeliness standards based on NCQA requirements

Created clinical reviews to support determination of medical necessity

Processed denials and appeals for pre-service and retro files

Sent denials and appeals to medical directors for second review

Emailed vendors and coordinators to notify overturned or upheld cases

Analyzed and resolved verbal and written claims and authorization appeals from providers and pursued resolution of formal grievances from members

Prepared response letters for member and provider complaints, grievances, and appeals

Assisted with HEDIS production functions including data entry, calls to provider’s offices and claims

SUNSHINE HEALTH (CENTENE CORPORATION), ORLANDO FL

02/2018 - 06/2021

Utilization Management Reviewer

Reviewed charts in TruCare to ensure all documentation for members were accurate and received

Created, documented, and collected appropriate clinical information from providers to make determination of medical necessity

Maintained communication with medical directors regarding review and assessment of criteria

Processed medical reviews, denials, and approvals in TruCare

Contacted providers via phone or fax to notify of approvals, appeals, denials and to obtain additional information needed for review

Sent denial and approval letters to providers, servicing facilities, primary care physicians and members

Complied with authorization timelines standards based on NCQA requirements

OPIS HEALTH CARE CENTER, LONGWOOD FL

11/2017 – 02/2018

Floor Nurse

•Managed the nursing care for all patients in the unit

•Delegated tasks to all the nurses in the unit and assisted physicians

•Recognized changes in patients’ condition and responded appropriately

•Supervised Nurses Aids while completing their tasks

•Detected any issues that could result in injury or other difficulties for patient or staff members

•Informed physicians of any changes in patients’ condition

SPRINGFILED PUBLIC SCHOOLS, SPRINGFIELD CT

12/2016 – 08/2017

School Nurse

•Triaged middle and high school students

•Administered oral medications, injections and conducted health screenings

•Managed student health conditions

•Created medical referrals and obtained physicians orders

•Provided parent and student health and sex education

•Administered drug screenings

•Processed student health records and immunizations

•Managed emergency plans for students requiring CPR with diagnosis of epilepsy, diabetes, allergies, respiratory, cardiac, and developmental issues

HARTFORD HEALTHCARE AT HOME, BLOOMFIELD CT

06/ 2016 – 12/2016

Revisit Nurse

Provided homecare to patients with a plethora of health conditions

Visits consisted of interventions, assessment, wound care, medication administration and management, instructing/educating, producing medical referrals, and coordinating care

NEW ENGLAND HOMECARE, CROMWELL CT

08/2011 – 06/2016

Utilization Reviewer/ Managed Care

Submitted prior authorization requests to insurance companies via portal, fax, and phone

Informed behavioral health team of discharges and changes in patients’ condition

Reviewed emails, faxes, face-to-face communication, phone calls, cases in tickler, all clinical information, ICD 9 and 10 coding, medical orders, medical home visits made by nurses, and authorization letters

Sent requests to confirm insurance verification

Produced charts, ticklers, and Excel sheets

Reported inconsistencies or discrepancies in medical orders and authorization letters to clinical supervisor or insurance companies for correction

Managed denial letters and processed appeals for approval

Updated authorization screens and assisted disciplines with questions pertaining to requests

NEW ENGLAND HOMCARE, CROMWELL CT

08/ 2011 – 06/2016

Pediatric Nurse

Provided care to children with gastrointestinal tubes, jejunum tubes, ventilators (i.e., Trilogy, Newport, and LTV), tracheostomies, IPV therapy, nebulizer treatments, cough assist, chest percussion, and vest therapy

Assisted with activities of daily living and patient care plans, administered medications, and provided documentation

EDUCATION

GOODWIN COLLEGE-1 RIVERSIDE DR, EAST HARTFORD, CT

05/2008

Associate in Science, Licensed Practical Nurse

Honors (GPA 3.8)

CERTIFICATIONS

BLS and IV Certified

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