Case Management Occupational Health
Resume:
Barbara S. Wilson RN, CCM
**** ******* ******** ****. #***
Sarasota, FL 34238
************@***.***
************@*****.***
PROFESSIONAL SUMMARY
I have over 30 years in nursing experience, with seven years in supervision/management.
Four years of Occupational Health experience in a manufacturing union environment.
Ten years in Case Management for major Ohio Health Insurance Companies, working with Oncology and catastrophic cases.
Eight + years of Utilization Review experience.
Over five years of experience in a Managed Care Organization setting.
Five years as a Quality Improvement Manager of a Managed Care organization.
I have valuable experience in interpreting plan language and medical policy criteria.
An excellent knowledge of Milliman and InterQual and proper application.
Experience and knowledge in Independent Review Organizations, Medicare and Medicaid products.
Having great communication skill with an aggressive case-management and utilization review history has led to substantial company savings. Years of patient care, and assessment skill has brought a broad range of medical knowledge to the table to assist clients / patients / members in meeting goals. Extensive experience in quality improvement and audit completion to compile trends, that in turn assists in process improvements.
EDUCATION
Northwest State Community College, Archbold, Ohio.
Certificate for Licensed Practical Nurse 1990
Associate Degree, Registered Nurse 1992
CERTIFICATIONS
Certified Case Manager (CCM)
Florida RN Multi-State Licensure
Licensed all non-compact states of the United States
SIGNIFICANT ACHIEVEMENTS
As an Occupational Health nurse, I decreased the number of OSHA recordable accidents from 27 in the year 2000, to 11 in the year 2002, and 9 in the year of 2003 through improved safety, ergonomic practices, staff education, and aggressive case management of work related injuries.
As an Occupational Health nurse, I decreased the workers compensation cost 290,000 in the year 2000, to $29,000 in the year 2002, and less than $10,000 in the year of 2003.
As an Occupational Health Nurse, my aggressive case management and safety education allowed this company to celebrate, never before in their history, over one year and greater than 500,000 man-hours with no loss time injury.
As an Occupational Health nurse, I established an aggressive case management program to allow employees to use a transitional work program to get back to work sooner.
As an Occupational Health nurse, I organized the FMLA process which allowed closer monitoring of its use and the number of hours used more accurately.
Managed the Quality Assurance/Quality Improvement Program to have an improvement in all areas as demonstrated by the audits completed by Bureau of Workers Compensation (BWC), lead the company to improvement in successfully passing of BWC on-site audits and URAC re-accreditation for the first time in this company’s history.
EMPLOYMENT HISTORY:
Centene – June 2022-under temp position. Hired on 9/26/2023.- CURRENT
Duties: Utilization Review in authorization of home health care needs. Review of OASIS and medical records. Collaborate with other departments to ensure member gets the best care under this Medicaid plan. Summarize the member history/medical needs to provide to medical director on care for members. Majority of the cases were critical care for children.
Optum - June 2020 to June 2022
Duties: RN Telehealth on the Nurse Advise Line for active and retired military and their families. Triage medical issues and symptoms to assist with the best level of care. Make recommendations to the beneficiary on how to care for their particular symptoms. Educate beneficiary to assist in gaining knowledge and empowering them to care for themselves. Training in Dual Medicare/Medicaid pre-authorization.
TEMPORARY EMPLOYMENT: after moving to Florida from Ohio
AllMed Inc. - June 2018 to September 2018 -temp position
Duties: Working for an Independent Review Organizations. Assisting the physician medical
reviewers to organize the needed information to ensure their decision is based on medical
policy, plan language, and/or medical necessity.
Anthem Blue Cross - October 2018 to July 2019 -temp position
Duties: Working for a major health insurance company, completing utilization review for
post-acute cases. Managing members in skilled nursing facilities, acute inpatient
rehabilitation centers, and long-term acute hospitals with Medicare product.
CareCentrix - July 2019 to June 2020 - temp position
Duties: Working with Florida Medicare companies, by completing utilization review for post-
acute cases. Nurse Liaison for Acute setting to assist in transitioning patients to a lower
level of care timely and safely. Managing members in skilled nursing facilities, acute
inpatient rehabilitation centers, and long-term acute hospitals. Assisting with new hire
training, and resource person for team.
**OHIO COMPANIES while residing in Ohio:
American Health Holding (Aetna Company) - September 2013 to May 2018
Duties: Utilization review of acute inpatient, oncology cases, acute rehabilitation, skilled nursing facilities, LTACH, procedures, and home health care needs and also held a Telephonic Utilization /case manager, managing oncology, and catastrophic cases. Excellent knowledge of Milliman and InterQual. Educator and resource person to assist members to ensure a maximum level of independence with health coaching.
Provide care management interventions to Oncology patients, and catastrophic cases, that assist in maximizing patient outcomes. Empowering and motivating members by teaching them supportive and problem -solving skills. Specialty pharmacy experience. Working directly with physicians, nurses, discharge planners, social service, and case managers to collaborate and meet the patients’ needs.
CareSource - June 2012 to September 2013
Duties: Telephonic and face-to-face nurse case manager, managing high risk Medicaid members. Educator and resource person to assist members to ensure a maximum level of independence. Provide care management interventions that assist in maximizing patient outcomes. Empowering and motivating members by teaching them supportive and problem-solving skills. Working directly with physicians, nurses, discharge planners, social service, and case managers to collaborate and meet the patient's needs. Monitoring patient progress and attending medical appointments with members as needed. Meeting the patient at least quarterly face-to-face in their home, public meeting area, or at medical appointments.
Nursing Experience from 1992 thru 2012
Occupational Health Nurse in an industrial setting x 5 years.
Quality Improvement Manager-Managed Care organization setting for BWC x 5 years
RN Staff Nurse for medical surgical unit and transition care units,
RN Case Manager home visits.
RN Restorative Coordinator for Skilled nursing facility,
Case Manager for insurance company
REFERENCES
Available upon request.
Contact this candidate