Case Manager Registered Nurse
Resume:
Francine Morgan, RN, CM, BSN
Mobile: 213-***-****
Email: *********@***.***
Accomplished Registered Nurse Case Manager and Clinical Nurse Supervisor with experience in inpatient acute care, critical care, acute rehabilitation and behavioral health.
Comprehensive knowledge of related regulatory, compliance and accreditation standards: Centers for Medicare and Medicaid (CMS), NCQA, Joint Commission related to clinical documentation, nursing care, care coordination, utilization management, utilization review, case management, social services, and discharge planning.
Experience:
Optum 03/2022 to 06/2024
RN Case Manager
Utilize the Nursing Process to assist members w/
educating and empowering them to manage their health conditions
Help members maintain their health conditions and prevent other comorbid
conditions from developing.
Assist w/removing barriers that prevent members from adhering to the individualized treatment plan.
Collaborate w/the multi-disciplinary team to get the best outcome for the members.
RN Call Center Nurse
Triage members via outbound or inbound calls to assess their needs and concerns.
Offer the appropriate referral program that meet their needs upon consent.
Provide Care Coordination for members whose health conditions are maintain or decline referral program.
Provide resources to members.
Molina Healthcare Inc 08/2016 to March, 2022
Inpatient and Concurrent Review RN
Review for medical necessity for Acute, SNF, Rehab stays w/InterQual criteria
Follow the process of Turn Around Time.
Send reviewed cases to Medical Director per Work Flow process.
Notify Provider of approved or denied stays per Work Flow process.
Denial Letter Review Nurse
Ensure to follow privacy rules when reviewing members’ medical records.
Review initial service requests of different HCPC or CPT codes.
Scan the medical records to make sure the denial verbiage supports the medical records.
Review and have basic knowledge of varied criterion sets: Inter Qual, MCG, CMS: NCDs & LCDs of denied cases.
Procel Nurses 06/2012 to 08/2016
Contracted RN Case Manager and Utilization Reviewer at:
-Providence Little Company of Mary Medical Center
-Regional Business Office
-Citrus Valley Medical Center
-Keck USC Medical Center
-Kaiser Permanente LAMC
Utilization Review & Discharge Planning
Grievance and Appeal Coordinator for Commercial & Medicare cases
Utilization review of acute inpatient and continued for medical necessity;
Participation in multidisciplinary team meetings
Coordination of discharges
West Los Angeles VA Medical Center 08/2014 to 03/2015
RN Case Manager and Utilization Reviewer - Inpatient and outpatient settings
Utilization Review for insured members
Utilization Management for outpatient procedures and inpatient admissions
Collaboration with health care providers and health plans on behalf of our insured members.
Mediscan Staffing Services 09/2010 to 8/2017
Contracted RN Case Manager and Utilization Reviewer at:
-St-Vincent Medical Center
-Whittier Community Medical Center
Assess and evaluate nursing care issues
Identify relations between collected data
Take appropriate measures to mitigate the impact on patient care
Organize activities with medical and health care services
Evaluate patients’ clinical conditions and document need for inpatient/outpatient acute care
Refer high risk patients to appropriate services
Interact with hospital staff, patients, and family members to assure patient is moved appropriately throughout the continuum of care.
White Memorial Medical Center 12/2007-01/2010
Clinical Step-Down ICU Registered Nurse
Perform Head to Toe Assessment.
Prioritize patients’ care per needs.
Utilize the Nursing process when providing care.
Collaborate with multidisciplinary team in patients’ care.
Educate and evaluate patients about their health problems.
Advocate for patients.
Nurses’ Internet Registry-
California Medical Center 11/2004-03/2007
Registry RN Telemetry Unit/ Orthopedic Unit
Follow the nursing process to provide patients’ care.
Advocate for patient.
Good Samaritan Hospital 07/2002-07/2004
Registered Nurse assigned to the Medical Surgical Unit
Performed Head to Toe Assessment.
Administered and monitored medications.
Provided safe individualized care per patients’ needs.
Collaborate with other team members.
Education:
University of Phoenix Gardena, CA
Major Nursing & graduated with BSN Degree
Los Angeles Southwest College, Los Angeles, CA
Major Nursing & graduated with an ASN Degree
Certifications and Licensure
California Registered Nurse license
Case Management Certification by the American Nurses Credentialing Center
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