Case Manager Registered Nurse

DT

OBJECTIVE

I am an experienced, knowledgeable, friendly, personable, very well versed Registered Nurse of over 30 years, previously Licensed Vocational Nurse. I have experience in numerous areas of expertise including Revenue Integrity Nurse Auditor, Appeals, Operating Room Nursing, precertification nursing, utilization review, case management, and physician office nursing. I am seeking a permanent position where I can excel with my employer and expand my nursing experiences.

SKILLS

I have experience with Microsoft word, Excel, Power point, Milliman, Interqual, claims review, ICD 10, HCPCS, Appeals, Chargemaster review, DRG reviews/appeals. I pick up jobs very quickly and am able to carry a lot of job duties at the same time. I have excellent people skills and always have a smile on my face while speaking to people, even over the phone. I am very flexible.

EXPERIENCE

Code Compliance Nurse / Nurse Auditor / Appeals Nurse November 2022- October 2024

PSN Affiliates

Job duties include utilizing multiple computer systems to research medical charts and claims and coding for 12 facilities to audit clinical procedures. Completed appeals for all 12 facilities with multiple insurance carriers. Completed chart audits and DRG downgrade appeals for IP facilities. Created SOP and Document Improvement presentations. Provided educational tools to help physicians and facilities learn about required documentation required for proper reimbursement from insurance and workers compensation programs. Composed multiple charts and spreadsheet for quick and easy access for specific insurance requirements for each procedure. Worked closely with CFO, CNOs and upper management on documentation education for physicians and facilities. I also work close with physician offices, VOB teams and claims department on correcting missing charges and overages.

Revenue Integrity Nurse Auditor April 2020-August 2022

Steward Health Care-CBO West

Job duties include researching and auditing charts as well as verifying correct coding used to assist in accurate billing for several hospitals and clinics. 100% line by line charge audits Verified correct coding for procedures. Utilized multiple systems for several facilities to verify charges matched claims and are correct to release clean claims for quick payments. Worked closely with physician offices, VOB teams and claims department on correcting missing charges and overages.

Registered Nurse, Utilization Management Coordinator July 2019 – April 2020

BCBS Texas.

Job duties include using Milliman criteria to perform initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and Medical and Network Management Divisions. I also review service requests, collect clinical and non-clinical data, verify eligibility, determine benefit levels in accordance to contract guidelines, prepare reports on quality of care, identify and report cases, and provide information regarding utilization management requirements and operational procedures to members, providers and facilities.

Registered Nurse, Certified Senior Case Manager, Inpatient UM November 2013-July 2019

HealthSmart Benefit Solutions.

Job duties include assisting members get the most of their benefits for the least amount out of their pockets by helping them navigate through the healthcare system. Used criteria required, including Milliman, Aetna and Cigna policies, to preauthorize Inpatient stays as well as spinal surgeries. I also work closely with doctors, hospitals, home health companies, outpatient facilities and the members to help the members stay in network and guide them to the closest in network facilities in which they need to be seen or admitted. Work within the Milliman guidelines to determine suggested length of stays and criteria required to provide recommended services.

Registered Nurse, Case Manager, Team Lead June 2012-November 2013

Arkansas Blue Cross Blue Shield, Dallas, Tx

Job duties include managing a team of eight to ten case managers in their daily assignments. Monitored and guided case managers in making informed decisions in care regarding insurance questions and member education with chronic diseases such as diabetes, CHF, CAD, asthma, COPD, Renal Disease, also cancer. Also, was responsible for running reports, communicating with medical director, director, manager and other team leads. As a team lead, I also assisted CM’s with reviewing appropriate levels of care for members and negotiations as well as identifying potential cases and interventions for continuum of care within URAC standards.

Registered Nurse June 2012-November 2013

Arkansas Blue Cross Blue Shield, Dallas, Tx Job duties include assisting members get the most of their benefits for the least amount out of their pockets by helping them navigate through the healthcare system. I also work closely with doctors, hospitals, home health companies, outpatient facilities and the members to help the members stay in network and guide them to the closest in network facilities in which they need to be seen or admitted. Work within the Milliman guidelines to determine suggested length of stays and criteria required to provide recommended services.

Registered Nurse Jan 2010-June 2012

Cook Children’s Hospital Northeast Hurst, Tx. Job duties include Operating Room Nurse responsibilities such as scrubbing and circulating a multitude of specialties including

•General

•Endoscopy

•ENT

•Orthopedics

•MRI's.

Other responsibilities included assessing patients and assisting anesthesiologists and surgeons with their operating room needs, prepping patients, starting IV's, Chart audits, taking call.

Registered Nurse Oct-2008 – November 2011

Lone Star Endoscopy, Keller, TX

Job duties include Recovery Room and Preoperative nursing responsibilities which include admitting patients, assessing patients, starting IV's, computer charting, receiving patients and report from procedure room nurses and anesthesiologists, monitoring vital signs, patient intake, preparing patients and escorts for discharge, which includes: discharge instructions, removing IV's, how to reach physicians if any problems arise, post discharge.

Registered Nurse Jan-2003 - Feb-2012

Clear Fork Surgery Center, Fort Worth, Texas

Job duties include those of an Operating Room nurse. Scrubbing and Circulating several different specialties at several different facilities where there was a need for an additional nursing help. other responsibilities include assessing patients and assisting anesthesiologists and surgeons with their operating room needs, prepping patients, starting IV's and chart audits. Specialties include:

•General surgery

•Endoscopy

•ENT

•Orthopedics

Registered Nurse May-2004 - Jul-2006

Perioperative Nursing, Inc., Arlington, Texas

Job duties include those of an Operating Room nurse. Scrubbing and Circulating several different specialties at several different facilities where there was a need for an additional nursing help. Specialties include:

•General

•Eyes

•Endoscopy

•Orthopedics

•Pediatrics

•ENT

•Gynecology

•Urology

Registered Nurse Jun-2002 - Jun-2004

Arlington Memorial Hospital Arlington, Texas

I attended a nine-month Operating Room Internship program which trained me in all aspects of the operating room nurse, including scrubbing and circulating a multitude of specialties including:

•General

•Endoscopy

•Eyes

•Cardiovascular

•Gynecology

•ENT

•Orthopedics

•Urology

•Neurology

I also had additional training as the Laser Safety Officer where I was to oversee operations of CO2 and Alcon eye lasers.

Licensed Vocational Nurse / Insurance Verifier Feb-2000 - May-2002

Zale Lipshy Hospital Dallas, Texas

Job duties include calling a multitude of insurance carriers and confirming or denying status of insurance, receiving precertifications for patient’s hospital stays and surgeries, and communicating with patients and hospital employees effectively.

Licensed Vocational Nurse / Utilization Management May-1999 - Feb-2000

Heritage Southwest Medical Group, Dallas, Texas.

Job duties include clinical research, and clinical decision making for approving and denying home health and DME claims, communicating with patients, nurses, medical directors. Making sure all requests go through the proper steps before approving or denying any products or services for quality patient care as well as the best decision for the insurance companies, computer charting.

EDUCATION

Associate Degree of Nursing Jan-1990 - May-1991

San Jacinto College Central

Pasadena, Texas

Licensed Vocational Nurse Jan-1987 - Dec-1989

San Jacinto College South Houston, Texas

Certified Case Manager Dec 2013-Present

Licenses:

Compact Registered License, initiating in Texas April 2002-Present

LEADERSHIP EXPERIENCE

I was promoted from a Case Manager to a Team Lead and managed 8 Case Managers within the first year at Arkansas Blue Cross Blue Shield.

I was promoted from a Case Manager to a Senior Case Manager to help assist other case managers with questions regarding cases and computer assistance at HealthSmart Care Management.

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