LPN

Eartha Smith

Licensed Practical Nurse South Chesterfield, VA

Phone: 804-***-**** Email: ******.********@*******.***

Professional Summary

Licensed Practical Nurse (LPN) with over 10 years of experience in clinical utilization review, case management, and occupational health. Proven expertise in investigating medical disputes, analyzing clinical information, and ensuring compliance with State and Federal regulations (CMS, HIPAA, OSHA). Skilled at reviewing adverse coverage decisions, coordinating physician reviews, and formulating clear, professional responses to appeal requests. Adept at managing medical and behavioral health cases, ensuring timely resolutions and quality outcomes.

Core Competencies

Regulatory Compliance (CMS, HIPAA, OSHA)

Clinical Analysis and Decision Support

Medical and Behavioral Health Case Management

Medical Necessity Review (MCG Guidelines)

Independent Review Organization Coordination

Provider and Patient Education

Accurate Documentation and Reporting

Professional Experience

Perdue Foods LLC Prince George, VA

Occupational Nurse Supervisor 11/2021 – Present

Conducted pre-certification and medical necessity reviews for adverse coverage decisions, ensuring alignment with clinical guidelines and regulatory requirements.

Investigated medical claims and coordinated case reviews with physicians and external providers to resolve disputes efficiently.

Documented appeal findings and prepared detailed summaries with 98% accuracy, ensuring compliance with HIPAA protocols and internal policies.

Collaborated with claims teams to deliver timely responses and explain determinations to members and providers.

Key Achievement: Improved response time for disputed claims, reducing delays by 20%.

Care On Site/Advansix Hopewell, VA

Occupational Health Nurse 11/2020 – 05/2022

Managed injury and case reviews, prioritizing timely investigations and appropriate resolutions for employees' medical needs.

Coordinated care with safety managers, physicians, and external reviewers to ensure adherence to regulatory standards and benefit plans.

Educated employees about coverage, appeals processes, and resources for medical and behavioral health care.

The Towers Richmond, VA

Memory Care Director 06/2017 – 11/2020

Conducted in-depth reviews of medical records and treatment plans to address gaps and ensure compliance with evidence-based guidelines.

Facilitated pre-certifications and addressed coverage denials, providing clear communication to patients and families regarding appeal options.

Monitored outcomes for behavioral health and memory care patients, ensuring adherence to clinical protocols and improved access to care.

At Home Care Colonial Heights, VA

Skilled Home Health Nurse 03/2013 – 06/2018

Delivered comprehensive care in compliance with physician orders, focusing on medical and behavioral health conditions.

Maintained detailed, regulatory-compliant documentation using EMR systems to support quality outcomes and accurate reporting.

Education

Diploma in Practical Nursing Medical Careers Institute Richmond, VA 2009

Licenses & Certifications

Active Licensed Practical Nurse

BLS CPR Certification

Certified in Spirometry and DOT Drug Testing

Technical Skills

EMR/EHR Systems

Microsoft Office Suite

Clinical Documentation & Reporting Tools

Tailored Notes for Employers

Skilled at managing medical and behavioral health appeals with attention to regulatory compliance (CMS).

Proven ability to investigate adverse decisions, organize case reviews, and collaborate with physicians to ensure timely, professional responses.

Dedicated to ensuring quality care outcomes while maintaining compliance with State and Federal mandates.

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