Katheline Warren

**** ****** **

Torrance, CA ***03

Cell Phone 310-***-****

Email: ad4lhk@r.postjobfree.com

OBJECTIVE

I am actively seeking a position that not only fosters my personal growth, enhances my professional skills and knowledge, and presents new challenges but also offers the prospect of long-term growth within the company. Additionally, I am eager to contribute my expertise and extensive knowledge to contribute to the success of the organization.

WORK HISTORY

07/23- Current, Contingent Senior Registered Nurse, FEP PPO Post Service, Blue Shield of CA, CA, United States

Remotely perform clinical claim reviews and first claim level determination approvals for members using Federal

Employee Program (FEP) evidenced based guidelines, policies and nationally recognized clinal criteria. Conducts

clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance.

Prepare and present cases to Medical Director (MD) for medical director oversight and medical necessity

determination and communicate determinations to providers and/or members in compliance with federal and

accreditation requirements. Develops and review member centered documentation and correspondence reflecting

determinations in compliance with regulatory and accreditation standards. Triage and prioritizes cases to meet

required turn-around times. Identify potential quality of care issues, service or treatment delays and intervenes or as

clinically appropriate. Provide referrals to Case Management, Disease Management, Appeals and Grievance and

Quality Departments as necessary. Assists in the development and implementation of a proactive approach to

improve and standardize overall retro claims review for clinical perspectives.

07/21- 5/15/2023 Contingent Registered Nurse for various engagements, ClearLink Partners, South Charleston, SC

Remote Registered Nursed specializing in various aspects of utilization management in Managed Care settings including: Prior Authorization, Post Acute Reviews, Post Service Review, Inpatient and Concurrent Reviews,

Retrospective Reviews, Provider Dispute Reviews, Medical Claims Review and Case Management/Care

Coordination. Utilized clinical experience and skills in a collaborative process to assess, plan, implement,

coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

Applied evidence-based medical guidelines to resolve inpatient and outpatient services. Gathered clinical information and applied to the appropriate clinical criteria/guideline, policy, procedure and clinical judgement to render coverage determination and recommendations for continuum of care such as MCG, Interqual, Healthplan policy manuals, Medicaid Publications or Medicare guidelines. Communicated with medical directors, leadership, providers and other multidisciplinary team members. Identified opportunities to promote benefit utilization. Screened client, assessed, stratified risk, planning, implementation, monitoring, transition and evaluation..

06/18- 06/22 Clinical Audit Nurse, Managed Resources Jackson Health Systems, Miami, FL

Post Service and Retrospective Reviews for Inpatient, Observation and Pre-Operative admissions to Jackson

Health system to determine supporting evidence of diagnosis codes, diagnostic tests, and treatments meet

evidence-based medical guidelines: InterQual. Obtain maximum savings for clients by accurately analyzing and

processing medical documentation according to state laws, industry standards, and company policies and

procedures. Formulate clinical appeal letters for Medicare and Medicaid per state mandate statutes. Utilize

analytical skills and knowledge of healthcare regulations.

06/12-05/22 Utilization Management, Inpatient and Outpatient Case Manager, Cigna Healthcare, Glendale, CA

Remotely Managed and performed initial, concurrent, discharge and retrospective reviews. Utilized evidence-based medical guidelines to resolve the medical appropriateness of inpatient and outpatient services. Evaluate patient outcomes against nurse-sensitive indicators and participate in raising the standard of nursing practice when results are below benchmark. Use a population and evidence-based approach to determine the patient’s individualized priority goals and care activities in relation to: Nursing’s independent scope of practice (safety, comfort, hygiene, restorative measures, and health promotion); and in relation to the interdisciplinary plan of care. Evaluate the effectiveness of the plan of care by evaluating the patient’s response, outcomes, and changes in stability and makes recommendations for modifications to the plan of care. Develop a therapeutic relationship with patients and families. Reviewed medical records to verify that the content helps an appropriate level of care (inpatient, observation, bedded outpatients) or type of service. Facilitated authorization process for admissions and continued stays. Utilized knowledge of nursing process and pathophysiology to anticipate discharge needs. Interfaced with facility, the member, family, and other healthcare team members as well as internal matrix partners. Assisted in escalation in complex cases to appropriate internal matrix partners. Assist with appeals and peer to peer reviews. Assisted with Prior Authorization department.

10/14-02/20 Senior Care Review Clinician, Molina Healthcare, Long Beach, CA

Remotely collaborate with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge applying Interqual and MCG guidelines. Review ongoing clinical documentation for inpatient, outpatient, retrospective and post-acute reviews. Assess members for care needs, and develops treatment plan with practitioners, providers, members and support system. Ensures quality member care is provided. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. Assesses and responds to patient/family needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care. Initiate the necessary community resource referrals. Evaluate clinical information received from health plan and write various reports based on the clinical Information received. Ensures reports are completed with highest quality and integrity and that all work is in full compliance with federal and state mandates. Lead project role assignments, prioritizing and communicating to the team. Performed random monthly audits. Actively engaged with Management leadership team to define measures goals for organizational and department performance and developed tasks and resources to obtain them. Facilitated meetings to provide utilization department with findings and recommendations to remain in compliance. MCG certified.

04/05-07/12 Telehealth Registered Nurse/RN Care Manager, Healthcare Partners Medical Group, Torrance, CA

Provide professional telephonic nursing assessment, evaluation and advice to patients through use of established and approved telehealth protocols with physician oversight. Follow established clinical protocols/guidelines and provides appropriate patient instructions. Direct patients to appropriate levels of care based on assessment within HCP guidelines. Document authorizations for vendors and or outside services as appropriate. Complete medical documentation of telephonic assessment and disposition in Telehealth record. Responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing advanced nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management telephonically as the need arises. Pre- Authorizations for HMO cases and medical review for managed care organization. Reports finding to the Care Management department Supervisor / Manager / Director / in a timely manner.

4/08-1/09 RN Nurse Instructor, Career College of America, South Gate, CA

Provide guidance to faculty staff and students. Educate and assign assignments and develop coursework needed for instruction in a clinical setting. Establish and maintain relationship with new and existing clinical sites. Maintain continuous medical education and assure about the facility’s continuous medical education requirements. Instruct students on nursing process.

04/06-03/08 RN Case Manager, Vitas Innovative Hospice, Torrance, CA

Initiate appropriate interventions for patient and family upon admission to Vitas and provide a continuously appropriate, comprehensive and responsive plan of care. Collaborate plan of care with other disciplines (chaplain, social workers and physicians). Participate in interdisciplinary meetings to provide up to date and effective plans of care.

09/03-09/05 Registered Nurse, Cancer Care and Associates, Redondo Beach, CA

Initiate chemotherapy infusion by starting IV’s and accessing central lines. Monitor for side effects and unwanted response to chemotherapy and hematology drugs. Educate patient on chemotherapeutic drugs.

10/03-09/05 RN Clinical Supervisor, Maxim Healthcare, CA

Supervise license clinicians. Evaluate nursing competencies according to current nursing practice. Provide clinical leadership and guidance. Seeks to continually improve clinical and operational processes to enhance departmental accuracy and efficiency. Function as a resource and serve as a liaison between administration, providers, staff and other departments. Conducts quality improvement activities for clinical process. Provide continuously appropriate, comprehensive and responsive plan of care. Audit charts per JCHAO and medi-cal regulations,

08/02-07/05 Registered Charge Nurse, Little Company of Mary Hospital, Torrance, CA

Responsible for 33-Bed on Med-Surg oncology unit. Collaborate with house supervisors, nurse staffing office on admitting needs. Assist family and patients in understanding nursing process. Assist management team on chart audits, educational requirements and department needs. Assist in medical chart audits per JCAHO regulations.

07/01-08/02 Staff Registered Nurse, Little Company of Mary Hospital, Torrance, CA

Specializing in Telemetry and Oncology. ACLS and Chemo Certified. Patient care leader of 5-6 patients emphasizing on utilizing nursing diagnosis and evaluating response to care provided. Initiate pre-op and post-op protocol for surgical patients. Document accordingly using Medi-Tech.

EDUCATION

12/98-01/01 Mount St Mary’s College, Doheny Campus, Los Angeles, CA

Associates Degree, Nursing

REFERENCE AVAILABLE UPON REQUEST

04/06-3/08

Contact this candidate