Licensed Practical Nurse
Resume:
**** * **** ******* **** Unit *, Orlando, FL *****
************@*****.***
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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