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Medical Registered Nurse

Location:
Fremont, CA
Posted:
December 13, 2019

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Resume:

Ellen Melo RN

ada2i5@r.postjobfree.com

312-***-****

Professional Summary

● A multi-state licensed Registered Nurse with over 25 years of experience and training in various specialty areas of nursing; currently focusing in Acute Care Case Management (Utilization Review and Care Coordination).

● Functional knowledge of several different EMR system applications such as Epic, MCG, InterQual, Allscripts, Cerner, Midas, CuraSpan, Cerme,MediTech, etc.

● Strong advocate for patient rights and a firm believer in providing cost-effective, excellent care, without leveraging quality and patient's safety.

● Returning to complete RN -MSN training in Nursing, while continuing to work, and volunteer within the current community.

● Fluent in Spanish and Tagalog

Education

Chamberlain College of Nursing

BSN/MSN degree program

Expected to resume Winter 2019

Richard J. Daley College, Chicago, IL 2010

Associate Degree in Nursing with Honors

Memorial City Medical Center School of Nursing, Houston TX 1988 Graduated with Honors

Licensure /Certification

● Professional Registered Nurse in states of CA, IL, NM, NV, WI

● In review for RN BC CM ;CCM certification

● Certified UM Milliman Care Guidelines

● BLS

1

Professional Experience

Traveler DCP/CM-UM RN

Kaiser Permanente Oakland, CA Oct. 2019

Plains Regional Medical Center Clovis, NM Mar. 2019- Oct. 2019 Ascension Health System Milwaukee, WI Jul. 2018 – Jan. 2019 VHS Las Vegas, NV Feb.2018 – May 2018

● Followed patients from admission to discharge, making sure the current level of care was optimal; communicated necessary transition of care at the appropriate interval.

● Concurrent review and analysis of EMR documentation for medical necessity of bedding status.

● Assisted staff with researching resources for patients to provide discharge support and avoid variance days.

● Working knowledge of DRG/ICD codes and CMS reference materials.

● Collaborated with physicians, caregivers, patient, family, other departmental team members, and payor to proactively develop and implement a safe and appropriate discharge plan.

● Participated in team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Case Management meetings.

● Applied utilization review criteria to assess and document the appropriateness of admission, continued stay, level of care, and readiness for discharge; referred cases that required Case Management Director or Physician Advisor for further evaluation.

● Maintained working knowledge of Medicare, Medicaid and private insurance company coverage for referred products and services.

● Ensured that quality of care is maintained or surpassed by collecting indicators and variance data and reporting the information to the appropriate department; report and identifies factors indicating potential areas for improvement of care and services provided within the system. DCP/CM RN(RETURNING CONTRACTOR) Dec.2017 –

Feb.2018

Loyola University Medical Center Maywood, IL

● Reviewed daily unit census with the other CM staff, and took the patients assigned appropriate for a CM based on the acuity.

● Triaged all the patients on the roster based on their LOS, bed status and potential needs per incoming consults for CM.

● Attended and participated at the AM and PM unit interdisciplinary DCP huddles.

● Performed initial assessment on patients based on their needs for CM consult.

● Collaborated with physicians, caregivers, patient, family, other departmental team members, and payor to proactively develop and implement a safe and appropriate discharge plan.

● Referrals for discharge planning are based upon recommendations by the rest of the medical team members. Initial DCP is considered after the assessment and patients' clinical condition until team members have met with the patient and the diagnostic exams are completed.

● Assist with the prior auth for prescribed medications and treatments.

● Facilitate a safe and timely discharge as initially established while setting a patient up for an effective post-acute follow up plan with providers. 2

● Was flexible with unscheduled rotation to all units of the hospital and locations. CM/UM RN for NICU Jul.2017 – Sept. 2017

Northwestern Memorial Chicago, IL

● Conducted initial, concurrent, and at a time retrospective review for those who were classified under acute inpatient level of care.

● Reviewed medical records to determine approvals or denials for length of hospital stay based on the MCG

● Requested for determination of approval or denial for durable medical equipment, physical/occupational therapy and home health care authorization for the Maternal Child Health Area.

● Consulted with Medical Director on cases with denials of stay.

● Performed concurrent review of all acute and observation status to ensure pediatric admission criteria is met accordingly whether using InterQual Criteria IS/SI, Milliman Care Guidelines depending on the specific health plan.

● Collaborated and coordinated care according to established guidelines with the member, PCPs/ IPA Health Plan Coordinators, facility CM/UM staff, and Community Case Workers.

● Ensured smooth facility to facility transfer took place when request was made during the office hours or when a procedure is anticipated to be performed at a sister hospital on a specific date, RN processed all the prior auth required for the treatment and transport.

● Patients’ parents, legal guardians, and Attending Providers were kept updated on their child/ patients CM status at all times. Traveler DCP/UM/Trainer/Case Management RN

Shady Grove Adventist Hospital Rockville, MD Apr.2017 – Jul.2017 Fairmont Regional Hospital Fairmont, WV Jul.2016 – Apr.2017 University of Chicago Medicine Chicago, IL Aug.2015 – May 2016 Valley Health System Las Vegas, NV Mar.2015 – Jul 2015

● Conducted initial, concurrent and retrospective review of inpatient, observation and outpatient patients.

● Reviewed medical records to determine need to request for additional auth for extended length of hospital stay.

● Performed concurrent review of all acute and observation inpatient status to ensure admission criteria is met according to InterQual Criteria IS/SI, Milliman Care Guidelines and/or specific health plan policy.

● Followed patients from admission to discharge, making sure the current level of care was optimal; communicated necessary moves from acute care to less intensive setting at appropriate intervals.

● Balanced the business and revenue needs of the organization with the patient care requirements. Met with financial and medical officers routinely to update them of the current outliers on the patient roster.

● Reinforced policies evaluate patient situations and weighed patients individual needs against the insurance coverage details; contributed to making final decisions on treatment, medications, surgeries and re-admissions.

● Assisted with training new staff and updated the department policy and procedures manual to reflect the current CMS standards.

● Assumed duties of a permanent staff Case Manager under a contract assignment as an Acute Care Case Manager

● Flexible rotation at various units depending on the departmental needs at all units including NICU, PICU, Maternal Child, Cardiology, Gen Meds, Gen Peds, Hem/Oncology, Adult ICUs, and Burn Unit. 3

● Performed Utilization Review, referral management, coordination of care based on the patient’s need.

● Prioritized variables that affected core outcomes, length of stay, and readmission rates on a daily basis at all of the units assigned.

● Facilitated effective transition of care as the patient’s medical condition allowed.

● Worked in tandem with the Medical Team (Residents, Fellows, and Attending), as well as other disciplines-assisted in carrying out an effective plan of care while observing cost effective measures.

● Attended and participated actively during medical rounds, discharge planning committees, in-unit huddles.

● Observed evidence-based practice as they applied in an academic setting that had a high ratio of medically complex cases.

● Performed first-level denial review from the concurrent and retro review census.

● Provided staff training, supportive work environment, and access to appropriate case management resources.

● Applied flexibility within the principles of clinical guidelines to approach highly-complex cases while ensuring safe discharge care.

● Coordinated care with the unit nursing and medical staff, as well as family members, offsite health plan CMs, facility liaisons, external providers, and clinical/social resources.

DCP/UM STAFF PER DIEM RN Jul.2014-Oct.2015

TENET Westlake Hospital Melrose Park, IL

● Identified and coordinated services both internally and externally; interacted extensively with case managers and physicians to determine follow-up care needs for discharged patients.

● Worked with insurance companies to determine allowable coverage; reviewed surgery and elective procedure schedules to make determinations on reimbursement rates.

● Performed Utilization Review, referral management, coordination of care based on the patient’s need.

● Prioritized variables that affected core outcomes, length of stay, and readmission rates on a daily basis at all of the units assigned. Perinatal Care Management Specialist MCO Health Plan RN Sep.2012 – Nov.2014 Family Health Network Chicago, IL

● Developed and implemented comprehensive, individualized care plans.

● Followed up with assigned clients to provide support, monitor progress on service plan, and provide access to resources.

● Provided ongoing support and resources to clients in unstable living situations.

● Worked as part of an interdisciplinary team to assist clients achieve case management goals.

● Served as patient advocate. Defends and preserves the rights of patients regardless of their gender or age and socioeconomic status.

● Followed up on the established DCP and confirmed that the Attending MD was in agreement to the team members recommendation. Ensured that the orders were appropriate and placed in the chart per CMS guidelines. 4

DCP/UM Provider Relations’ Case Manager for BCBS/HMOI/Access to Care Feb.2012 – Jul.2012 Loyola Medical Center Chicago, IL

● Performed concurrent review of all acute and observation inpatient status to ensure admission criteria is met according to InterQual Criteria IS/SI, Milliman Care Guidelines and/or specific health plan policy.

● Reviewed and initiated Telephonic Care Management enrollment of eligible members.

● Collaborated and coordinated care according to established guidelines with the member, PCPs/ IPA Health Plan Coordinators, facility CM/UM staff, and Community Case Workers.

● Performed outreach to educate participating case management enrollees of services that they may be eligible for.

● Performed 1st level denial reviews for concurrent members that belong under the IPA or the Provider Relations Health Plan groups.

● Initiated TOC assessments for new admissions. Determine an appropriate initial plan for discharge.

● Provided information on necessary community resources when applicable.

● Initiated referral to external facilities when appropriate or determines patient’s return status to the facility or provider's’ service.

● Managed all ordered IPA group referrals by verifying the appropriateness of request based medical necessity guidelines.

● Obtained benefits determination for complex referrals such as organ transplant, DME, external second opinion, and reproductive endocrinology.

● Reviewed all incoming admission from the ED and provided real bedding designation level after LOC was determined based on the criteria being met.

Home Health Case Management/ Clinical Supervisor 2010 – 2012 Interim Health Care Elmhurst, IL

● Functioned as a RN Case Manager, and Clinical Supervisor for the Continuous Care Division covering a wide range of patient populations with various complex medical conditions on a skilled and non-skilled level

● Coordinate care with patients, primary caregivers, physicians, ancillary personnel, and health plan representatives.

● Performed initial and intermittent comprehensive assessment for home care clients.

● Determine eligibility for services, plan, and submit for authorization of the necessary services, assist with reimbursement as needed.

● Establish, evaluate and revise necessary staffing needs for all home care cases.

● Provided staff and caregiver/patient education on an ongoing basis.

● Administered IV infusions for IVIG, Prolastin, C, TPN, Lipids, Antibiotics as ordered, and performed direct patient care to implement MD orders

● Keep an effective and clear line of communication with patients and/or primary caregivers, healthcare providers, insurance representative and/or case managers

● Ensure compliance with federal and state regulations, perform intermittent chart reviews, monitor and ensure appropriate documentation of services provided by field staff

Field Staff-Home Care 2001 – 2010

Addus Healthcare Services Oak Lawn, IL

Maxim Healthcare Oak Park, IL

5

● Provided high-tech care to patients with complex medical history such as ventilator dependent, tracheostomy maintenance, home- infusion therapy, wound care, etc.

● Performed comprehensive assessment, implement ordered EBP interventions, evaluate care application, and revise care to improve outcomes.

● Assumed permanent staff responsibilities according to facility and agency standards. Level III NICU/SCN Staff Nurse 2000 – 2002

St. Elizabeth Hospital Chicago, IL

Univ. of Illinois at Chicago Medical Center Chicago, IL

● Cared for High-risk neonates based EBP protocols, which were born prematurely and/or with complex congenital, chromosomal, or other medical conditions.

● Implemented care variation when clinical trials/experimental protocols applied.

● Provided parents with comprehensive teachings on unit environment, unit protocols, medical equipment, kangaroo care, breastfeeding/pumping, enteral feedings, diagnostic tests, developmental milestones, and other pertinent interventions.

● Floated out to the Medical-Surgical, Psychiatric, and Pediatric units as needed.

● Collaborated with Lactation Specialists at Cook County to establish and promote EBP lactation program. ER, NICU and IV Team Staff 1988 – 2001

The Women's Hospital Houston, TX

Memorial Hermann Memorial City & Northeast Medical Center Houston, TX

● Cared for neonates born with multi-complex problems r/t genetics, lack of prenatal care, multiplicity, severe premature birth, congenital/chromosomal anomalies, hyperbilirubinemia, RDS, sepsis, feeding intolerance, multiples, etc.

● Cared for infants that had UAC, UVC lines, receiving IVF's; were on mechanical ventilation, cardiac monitor, pulse oximeters, phototherapy, etc.

● Worked intermittently with the facility IV-Team and was responsible for all unit-assigned IVs or infusion therapy related issues such as Central line and peripheral line care and maintenance; initiate or revise peripheral access, respond to all RRT calls.

● Active participant during surveillance cultures and clinical trials of experimental medical and nursing interventions

● Assumed staff responsibilities while working as a temporary /float staff to various hospitals and patient units such as Med-Surg, Acute and Subacute Rehab, Mother-Baby, Telemetry, NICU, PICU, Peds, Outpatient Clinics, and Worksite/Occupational Health Volunteer and Nursing Organizations

● Chicago Thanksgiving Parade Leadership Board Member, Chicago Medical Reserve Corps, Dreams for Kids, ARC Disaster Health Services, Silent No More Foundation, Nurses Take DC, Show Me Your Stethoscope

● American Nurses Association, Case Management Society of America, Association of Women’s Health, Obstetric, and Neonatal Nurses 6



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