Case Manager Registered Nurse
Resume:
JOSEPH CORAL, BSN, RN, CCM
Email: ***********@*******.***
Executive Summary: Dynamic, qualified, and highly ethical Registered Nurse with extensive experience.
Objective: I can make a difference in outcomes for patients healthcare, due to my extensive experience With Medicare, Medicaid, and Commercial insurance.
It is with great interest that I am forwarding my resume for consideration as a Remote RN Utilization Review Nurse. Given my experience as Remote RN (8 years), combined with my strong educational background and passion for helping patients, I feel I would be an excellent fit for the role.
My goal is to utilize my clinical knowledge and experience as well as my education to provide the highest level of nursing care to patients. Please consider the following:
Commercial Health Insurance
Through a contract with Cognizant/E-solutions, worked at Healthnet of California/Medi-Cal (Centene Corporation), as a Remote/Appeals Review Nurse
Through a contract with Pyramid Associates worked at Ambetter2/Superior Health Plan (Centene Corporation), as a Remote/Utilization Review/Concurrent review nurse.
Through a contract with Pyramid Associates worked at Superior Health Plan (Centene Corporation), as a Remote/Denials Coordinator.
Wellmed Healthcare (telephonic work from home CCM). Following Medicare Advantage program patients through their stay in Skilled Nursing Facility. Proficient with Milliman Care Guidelines as well as InterQual guidelines.
Blue Cross Blue Shield of Texas (telephonic work from Home CCM). Two years+ as Certified Case Manager (CCM) for Federal Employees group, and as one of four Transplant nurses. PC proficiency, including Milliman Care Guidelines, Word, Excel, PowerPoint, ICD-10, DRGs.
Clinical Experience –Case Manager at Parkland Medical Center for three years. Experienced with Milliman Care Guidelines (MCG). Supervised two Social Workers. Familiar with URAC Guidelines. Familiar with NCQA standards. Registered Nurse with extensive experience providing nursing care to patients within a variety of hospital settings. InterQual experience.
Solutions- Oriented – Solutions-oriented expert in analyzing data, assessing conditions, resolving problems, and implementing appropriate strategies. Extensive experience in nursing and managing/administrative procedures.
Patient Care –US Citizen, US trained, US Veteran. Expert in patient management skills, providing superb customer service to patients, family, staff, physicians, medical teams, and increasing patient satisfaction.
I thrive in challenging and results-oriented environments, and it is these qualities that attract me to healthcare.
I would welcome the opportunity to discuss how I can address the unique challenges of this position. In the interim, I thank you for reviewing this letter and the accompanying material.
Sincerely yours,
Joseph Coral BSN RN
Certified Case Manager (CCM)
JOSEPH CORAL, BSN, RN, CCM
***********@*******.***
Certified Case Manager • Milliman Care Guidelines • InterQual• Medicare-Medicaid
Appeals Nurse • Discharge Planning • Concurrent Review • Removed Barriers to Care - Utilization Review • Completed Contracts • Conducted Meetings • Analyzed Patient Risk. Bachelor’s degree • Pharmaceutical Nurse Educator • Provided Education. Bilingual.
HCA Medical City Plano
Case Manager
August 19, 2024, to 11/08/2024
Assesses and identifies cases for interventions
Prioritizes goals and develops a plan to achieve clinical and fiscal outcomes
Monitors various aspects of client’s plan of treatment
Acts as a facilitator/leader of the multi-disciplinary team to coordinate the client’s plan
Interacts with the health care team to implement identified goals
Follow clients throughout the continuum of care for outcomes management
Accurate and timely data collection
Promotes effective resource utilization and appropriate levels of care
Cross train sufficiently to team member’s duties to be able to serve as back up resource.
Proactive case identification
Demonstrate behaviour supportive of team achieving department goals
Track and trend denial and appeals to identify issues and develop action plans for resolution
Actions demonstrate protection of patient privacy and compliance with HIPPA regulations
Appropriate and timely communication with third party payors to meet requirements for payment
Collaborate with third party payors internal case management/disease management departments as appropriate
Attendance and being on time, ready to work your scheduled hours is an essential job function.
Healthnet Medical Healthcare/Medi-Cal.
Contract through Cognizant/E-Solutions
Remote/Appeals Review Nurse Dec 2023 to Feb 2024
Reviewed first tier appeals from California providers whose claim for payment was denied due to various reasons, including not sending medical records for review. Main software used was InterQual and Macess. Also, Trucare, One Note, Excel, PSAS, Microsoft Teams. Participated in weekly rounds with my supervisor, manager, medical director and the entire team.
Ambetter2/Superior Health Plan, through Pyramid Associates.
Remote/Utilization Review/Concurrent review nurse Feb 2023-August 2023
Review telephonic and faxed clinical information to authorize medically necessary inpatient and outpatient care, utilizing nationally recognized evidence-based clinical criteria or approved medical guidelines. Refers cases that do not meet criteria to the Medical Director for review. requests for members at the time of discharge as well as new requests for members who have not had recent hospitalization. Review any requests for members who have not had recent hospitalization. Assists in discharge planning especially Home Health Nursing request and DME. Review any requests for extension of these services if not meet the criteria, refer to the Medical Director. Participates in community Nursing rounds if applicable with the medical director and is adequately prepared. Assist coworkers with difficult cases through open discussion. Communicate concerns that arise in these discussions to the manager and/or Medical Director.
Superior Health Plan (Centene Corp), Through Pyramid Associates. April 2022 - Sep 2022
Remote/Denials Coordinator
•Completed contracts and entered documentation into the Trucare system while supporting the care of members with telephonic interventions.
•Conducted virtual meetings to discuss advancements in care and deliver innovative ideas.
•Communicated with other healthcare professionals out in the community via telephone.
•Placed requests to DME companies for supporting equipment.
•Collaborated with MD offices for supporting documentation.
Integrated Resources Nov 2021 - March 2022
Covid 19 Tester, RN, on site.
•Delivered Point of Care Covid 19 RN tests and utilized Lumira Strips and Lumira Machines at CVS pharmacies through a contract with Integrated Resources Staffing.
AMC Health Sep 2021 - Oct 2021
Remote, Telehealth Case Manager
•Contacted patients to inquire about their well-being and address any concerns or questions.
•Assessed biometrics from digital correspondence & notified the MD of baseline deviances.
•Analyzed patient risk for compliance and adherence to treatment regimen while identifying barriers to care and referring to additional support services.
AmerisourceBergen Sep 2019 - Oct 2020
Pharmaceutical Nurse Educator, on site.
•Executed Dupixent program while addressing inbound calls and executing outbound calls to patients and other parties, providing emotional support, depending on program requirements. Pharmaceutica Call center.
•Provided disease process and drug support education while utilizing call guides/scripts.
•Collaborated on cross-functional teams (ex. reimbursement support) while applying an understanding of key principles of reimbursement, patient assistance, and co-pay assistance.
•Executed correspondence through web portal, patient assistance program, fax enrollment form, and electronic enrollment form or phone.
•Provided product/program information, sent out information kits, & advised on any side effects.
•Entered consumer activities accurately in Clinical Data Bases outlined in business rules.
•Documented all reportable activities accurately and on time in the Clinical Data Base.
Wellmed Healthcare/United Healthcare Aug 2017 - Aug 2019
Remote Certified Case Manager, Medicare Advantage Program
•Directed transfers to ARU and LTAC, and Out of Area (OOA) and Out of Network (OON).
Reviewed medical services. Used guidelines to assess appropriateness.
Evaluated patient needs and requirements.
My duties included reviewing medical records to confirm that the content supports an appropriate level of care.
Should I encounter cases not meeting medical appropriateness criteria, I would alert relevant teams and coordinate actions during denials.
As part of Case Manager role, I also helped streamline the authorization process and anticipate discharge requirements.
Clear communication of issues or trends impacting specific entities to the appropriate management is expected.
Part of my work will involve identifying and conveying potential quality assurance or risk management issues.
To improve patient care, I joined projects to enhance care coordination and implement evidence-based procedures for best standards.
To enhance the relationship with providers and members, I also performed service recovery tasks.
Blue Cross and Blue Shield of Texas Oct 2014 - Dec 2016
Remote Certified Case Manager
•Saved $1.3M for Blue Cross Blue Shield while directing patient cases telephonically in 5 states.
•Identified over $1.3M in savings while providing case management in a team of 4 CMs for transplant cases, heart, liver, pancreas, and kidneys.
Parkland Medical Center, Dallas TX June 2011 - June 2014
Case Manager, on site. MICU and Med-Surg.
•Recovered insurance denied charges for 21 patient accounts, before the installation of the utilization review department in the facility, saved significant revenue.
•Directed 2 social workers while providing aiding and orienting new CMs and delivering case management for the Medical ICU and Medical floor.
•Provided prompt transfer arrangements to other facilities.
•Applied principles of Milliman Care Guidelines and URAC.
Prior Experiences: Baylor Regional Medical Center, Charge RN Telemetry Unit; Methodist Dallas Medical Center, PCU Staff Nurse; Medical City Hospital, MICU Staff Nurse; Sierra Providence Health Network: Providence Memorial Hospital, ICU Staff RN
EDUCATION
University of Texas School of Nursing (UTHSC-Houston)
Bachelor of Science, BSN. Registered Nurse, Graduated 1997.
Houston Community College, Health Careers Campus.
Associate Degree, ADN, Registered Nurse, Graduated 1988.
TECHNOLOGIES, CERTIFICATIONS, & LICENSES
Technologies:
Allscripts, Trucare, Milliman Care Guidelines, InterQual, Excel, One Note, PowerPoint, Word.
Certifications:
Certified Case Manager, CCM, 4209699, expires 05/31/2026
Licenses: Registered Nurse License
Compact states.
CA RN 95211690 expires 02/28/2025
TX RN 547130 expires 01/31/2026 Multistate Compact License
References:
Gayla Wilson MSN
Supervisor at Cognizant
*****.******@*********.***
Cassie Seitz NP
Reference managed me at CVS
**********@*******.***
George Silvosa NP
Reference managed me at CVS
***********@*****.***
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