LICENSURE AND CERTIFICATIONS

Certified Case Manager (CCM-BC), experienced traveler and multi-state Registered Nurse: IL, TX, KY, HI, NY With Both CA and WA in Progress.

MCG Certification: In Progress.

Member: AMERICAN ASSOCIATION OF OCCUPATIONAL HEALTH NURSES (AAOHN).

Member: THE NATIONAL SOCIETY OF LEADERSHIP AND SUCCESS (NSLS).

MEMBER: AMERICAN NURSE’S ASSOCIATION

MEMBER: ILLINOIS NURSE’S ASSOCIATION.

Five + years of experience as a Primary Nurse Case Administrator in BCBSIL.

Twenty-three years’ experience as an RN Case Manager in various trauma level facilities up to 660 beds.

Areas of expertise include, Admissions, Discharge Planning-including Complex, Prior Authorization, Concurrent & Continued Stay, Retroactive Review, Escalations, Cost Management, Utilization Review, Transferring, Transportation, Patient Assistance Programs, Department of Child Services, Department for the Aging and Homeless Shelters.

Units: General Medical, Surgical, Cardiac, Cardiac Cath, Neurology, Oncology, Urology, Orthopedic, ICU, CCU, PACU, Emergency Department, Ambulatory, Pediatrics, Ante-Partum, Labor and Delivery, Post-Partum, OB/GYN, Outpatient Clinics and Hospice.

Has current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payor sources.

Proven abilities to execute timely reviews with the interdisciplinary team to ensure that the care and services provided are medically necessary, delivered efficiently and timely, and at the appropriate level of care to meet payor requirements and established financial and performance benchmarks.

CRITERIA AND SYSTEM EXPERIENCE

Aerial, MPUI, ECM, Real Time Benefits (RTB), Smart UM, Cisco Finesse, and NICE. InterQual, MCG, Midas, McKesson, Meditech, HMS, Emtek, Logicare, Care Connection, Black Board, Microsoft Suite. ACE Training. MCG Certification: In Progress.

CAREER EXPERIENCE

Health Care Services Corporation (HCSC)/Blue Cross Blue Shield (BCBSIL)

Primary Nurse Case Administrator: 01/07/2019 - Current - Hours: Full Time

-Transplant Team Member

-Bright Blue Ideas and Innovation Committee Member

-Weekend Coverage Pilot Volunteer

-Remote Monitoring Pilot Volunteer

-Covid-19 Task Force Volunteer

-HEDIS Pilot Volunteer

-2024 Readmission Rate Reduction Team Pilot.

-2024 EPIC with NMH Pilot Volunteer.

Performing functions of Case Management by acting as a single source of contact for members, health care personnel and all other entities involved in managing care. Performing discharge planning and care coordination; identify alternate treatment programs; consult with physicians, providers, members, and other resources to evaluate options and services required to meet an individual's health needs; promote quality and cost-effective outcomes; and serving as liaison to physicians and members. Other functions also include episodic case management, and pre-admission/post-discharge counseling for acute and chronic conditions. Establish relationships with the member through the immediate post discharge follow-up period or until all short-term care needs are met. Provide education/local resource information and encourage member (self) education. Functioning in a clinical care advisory role to assess members for wellness education and disease management, introduce members to our website tools, educate members regarding wellness and specific conditions, and facilitate the coordination of care for identified members.

Lourdes Mercy Health (303 beds, Medical-Surgical Hospital), Paducah, KY

Registered Nurse Case Manager: 04/2015- 12/2019 - Hours: Full Time

Performing care management duties to assess, plan and coordinate all aspects of comprehensive patient/family care. Provide support services across the continuum of care to promote quality, cost effective care. Assessed the patients’ current health status, resource utilization, past and present treatment plan, services, prognosis, short and long-term goals with options and interventions.

Utilized assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet client(s) needs and promote desired outcomes. Coordination of services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio-economic needs of clients.

Patient and family education.

Facilitated client(s) access to community-based services. Actively participated in integrated team care management team meetings. Identified related risk management quality concerns and reported these scenarios to the appropriate resources.

Entered and maintained assessments with pertinent clinical information into the McKesson medical management system.

Direct patient care. Performed duties independently, demonstrating understanding of inpatient, outpatient, and hospice care management principles.

Leadership: Nursing Preceptor. Nurse Hospice Educator Liaison.

Prince George’s Hospital (156 beds, Medical-Surgical Hospital), Cheverly, MD

Registered Nurse Case Manager: 01/2015-04/2015 - Hours: Full Time

Utilization Review of each chart to evaluate criteria under Milliman screenings built into the Midas computerized system following guidelines to facilitate appropriate patient status.

Conducted admission, concurrent and continued stay reviews for all payer sources.

Ensured necessary clinical information is delivered to insurance companies as required and requested.

Personal Time Off

Tunnel Hill, IL

09-2014 – 12-2014

Venice Regional Bayfront Health (312 beds, Trauma Level 3 Acute Care Hospital), Venice, FL

Registered Nurse Case Manager: 04/2014-08/2014 - Hours: Full Time

Utilization Review of each chart to evaluate criteria under InterQual and Milliman screenings built into the Midas computerized system following guidelines to facilitate appropriate patient status.

Conducted admission, concurrent and continued stay reviews for all payer sources.

Ensured necessary clinical information is delivered to insurance companies as required and requested.

Advocate Trinity Hospital (186 beds, Trauma Level 2 Medical Surgical Hospital), Chicago, IL

Registered Nurse Case Manager: 11/2013-03/2014 - Hours: Full Time

Role as a case manager included coordination and integration of case management functions into the patient care, planning, and discharge processes with other hospital departments, external service organizations, agencies, and healthcare facilities.

Reviewed and audited each chart to evaluate criteria under InterQual guidelines to facilitate appropriate patient status.

Conducted admission, concurrent and continued stay reviews for all payer sources, including adherence to all CMS regulations.

Screened high risk patients for appropriate discharge needs and planning.

Heartland Regional Medical Center (298 beds, Trauma Level 2 Hospital), Marion, IL.

Registered Nurse Case Manager: 01/2012-11/2013 - Hours: Full Time.

Leadership: House Case Manager and Nurse Case Management Preceptor.

Arranged DME, home health professionals, homemaker services, skilled nursing home placement, acute rehabilitation placement, long-term acute care hospital placement, hospice, DCFS and Shawnee Alliance referrals, as well as applications for medication assistance programs.

Ensured necessary clinical information is delivered to insurance companies as required and requested.

Some other duties included physician adviser referrals and insurance appeal and denial data entry and review.

Initiated Code 44 forms, HINN letters and IMM notifications as appropriate per CMS regulations.

Assisted in achieving desired clinical outcomes within the desired time frame by adhering to departmental goals, objectives, standards of performance, and policies and procedures.

Abbott Laboratories (Pharmaceuticals, Medical Devices, Nutritional Products), Deerfield, IL.

Registered Nurse Contractor: 12/2009-11/2013 - Hours: Full Time

Pharmacovigilance: Post-Marketing Safety Division: Adverse Events, Medical Information and Quality Departments.

Maxim Home Health Care, Oak Park, IL. and Amedisys, Inc., Oak Park, IL.

Registered Nurse Case Manager in Home Healthcare: 09/2006-12/2009 - Hours: Full Time

Advocate Lutheran General Hospital (648 beds, Level 1 Trauma Center, Magnet Status Hospital), Park Ridge, IL.

Leadership: RN Charge Nurse, Nurse Case Management Preceptor and Facility Mechanical Ventilation Liaison.

Staff nursing, charge nursing, nurse/student precepting.

Population served: inpatient traumatic, acute, sub-acute, chronic, rehabilitation and hospice.

Specialty: respiratory, tracheostomy, mechanical ventilation.

Patient Satisfaction Committee Chairman representative.

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