Data Entry Utilization Management
Resume:
Samerah Ropp
Licensed Practical Nurse
Galloway, Ohio 43119
(P) 614-***-****
********@*****.***
Extremely motivated LPN with 10 years’ experience and a very keen individual with expertise; highly articulate and effective communicator; works well with individuals on all levels; distinguished as a team player, problem solver and a resourceful person; excellent ability in making plans for utilization and expansion; effective in identifying new opportunities; vast experience in developing strategies; possesses good interpersonal skills and team interactions to work with a variety of professionals.
Skills:
Data Entry, Microsoft, Strong Communication and Interpersonal Skills, Detail Oriented, Staff Development and Training, Time Management, Utilization Management, Proficient with InterQual Criteria, Molina Guidelines, NCQA, Medicaid and Medicare Guidelines, Psychiatric Care, Nursing
Work Experience
Sun Behavioral Columbus Oct 2017 – Present
Utilization Management Nurse:
●Reviews patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
●Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.
●Provides thorough documentation and timely updates regarding patient status that are prepared for daily meetings concerning admissions, reviews, and discharges; including cases with limited benefits, cases in peer review/denial and/or unplanned discharges.
●Coordinates with managed care companies or other third-party payors regarding peer reviews, retrospective reviews and appeals.
●Comprehensive understanding of the admission, concurrent, continued stay and retrospective reviews using the established hospital criteria.
●Communicate professionally and effectively, orally, in person and in writing with multidisciplinary team members, managed care organizations, providing need information in a logical, concise manner using technical language that accurately describes patient’s condition and needs for hospitalization.
Molina Healthcare Aug 2011 - Jun 2017
Utilization Management Nurse (Remote):
●Reviewed clinical information provided with request and determines if it meets InterQual criteria. If meets medical criteria will authorize service(s) and enter clinical data and authorization services appropriately in QNXT.
●Assessed services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
●Analyzed clinical service requests from members or providers against evidence based clinical guidelines.
●Conducts pre-certification, concurrent, and retrospective reviews of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits and contracts.
●Rendered a determination on whether the denied/downgraded account is appealable.
●Prepared case review for the medical director in cases where criteria are not met based on the additional clinical information received
●Generated appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
●Requested additional information, as appropriate from provider(s) to facilitate timely appeals resolution
●Reviewed retrospective medical necessity appeals against medical review criteria to make benefit determinations.
Home Care Rx Aug 2010 - Oct 2011
LPN Home Health Private Duty Nurse:
●Administered meds and nutrition via G-tube
●Educated and supervised the patient and family members regarding self-care techniques, prevention strategies and nursing care needs
●Worked independently to deliver and coordinate quality patient care based on plan of care as well and family needs
●Provided continuous observation and assessment of patient’s condition and care needs and reported significant changes to supervisor and physician
●Performed trach care, suctioning and connected/disconnected to vent per schedule
●Performed daily assessments and documented all care and treatments
Pomegranate Health Systems Nov 2009 - Aug 2011
Psychiatric Nurse
●Conducted an initial assessment of resident to obtain a complete medical history and documenting identified concerns.
●Organized and updated patient charts and records by reporting vitals, medical history, treatment plans, current medications, medication reactions, allergies and health status information.
●Monitored and evaluated patients in the context of individual and group treatment for progress or the development of additional symptoms of mental/behavioral disorders
●Performed vitals/glucose testing and assisted in administering injections and urinalysis.
●Provided exceptional patient care by meeting physical, psychological and overall care requirements to support daily living needs and independence.
●Dispensed and administered patients' medications following care plans and physician's orders.
Totalmed Lab Jan 2003 -Dec 2006
Quality Assurance Assistant
●ICD- 9 Coding.
●Audited internal data entry for accuracy.
●Maintained quality of data entries in a database.
●Assisted department supervisor in the development of procedures for current operations.
●Printed routines to skilled nursing facilities in Columbus and surrounding areas monthly.
●Worked with new customers in the development of new accounts and the implementation of new systems.
●Strong interpersonal skills with customers.
Education/Certificates:
Bachelors in Healthcare Management
Franklin University January 2018-Present
Columbus State Community College March 2006 to June 2009
Certificate in Nursing (LPN.136044.MEDS-IV Exp : 10/2020 )
Basic Life Support Certification
Crisis Prevention Intervention Certification
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