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Registered Nurse Home Health

Location:
San Antonio, TX
Posted:
September 10, 2019

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Resume:

James Brown

EPSDT Coordinator for Quality Improvement - Centene Corporation

San Antonio, TX 78256

adabf3@r.postjobfree.com

210-***-****

Willing to relocate: Anywhere

Authorized to work in the US for any employer

Work Experience

Home Health Nurse

Accentcare / Texas Home Health - San Antonio, TX

March 2018 to Present

EPSDT Coordinator for Quality Improvement

Centene Corporation

July 2017 to March 2018

• Conducts trainings and answers questions for key health plan staff on EPSDT requirements and ensures understanding of state and federal EPSDT requirements. Educational and other information is shared through in-services, update notices and emails

• Conduct an annual evaluation of the processes and outcomes for EPSDT program and continuous quality improvement activities

• In-person visits with member and or personal representative to review and address concerns and issues (including compliance issues)

• Training to providers, community organizations and other identified groups to improve understanding of our EPSDT program, changes to the program and provision of information regarding community resources

• On-site training visits to the providers when requested

• Assist the health plan in meeting EPSDT quality requirements

• Design and manage specific Quality Improvement (QI) interventions related to ensuring member receipt of EPSDT services and the creation of health improvement strategies under the direction of the QM Leader or manager

• Assist with monitoring of EPSDT data entry efforts and support monitoring and execution of follow-up, coordination of care and referral activities based upon EPSDT data obtained from EPSDT forms

• Support and monitor health plan responsibilities associated with the Immunize Nevada (IN) program

• Develop provider and member education and training materials related to health promotion

• Meet with medical providers to discuss EPSDT and IN activities, requirements or performance

• Create and review reports for submission to health plan leadership or regulators Summarize data or other information using Excel, MS Access or other data manipulation software LPN/Homecare

Nathan Adelson Hospice

February 2017 to December 2017

• Provids direct patient care under the supervision of a registered nurse.

• Responsibilities include following the plan of care, providing treatments, and working collaboratively with the members of the team to help meet positive patient care outcomes.

• Provides hospice education to patients and to family/caregivers of patients.

• Maintains a working knowledge of community resources and assist patients in accessing those resources.

LVN/ CRC

Molina Health Care

August 2016 to February 2017

1 (Care Review Clinician)

• Works with the Utilization Management team and is primarily responsible for prior authorizations.

• Provides prior authorizations according to Molina policy.

• According to guidelines provides inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time.

• Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

• Consults with and refers cases to Molina medical directors regularly, as necessary. Service Coordinator L2

Centene Corporation

March 2015 to August 2016

for the STAR+PLUS MMP

• Ensure the Member's Medicare and Medicaid Services are provided.

• Utilize Care Management Teams for targeted Member outreach and care coordination.

• Improve quality and individual experience in accessing care by:

• Improving the coordination of care.

• Providing access to care in underserved areas - no traditional means of care

• Increasing primary care visits.

• Reduction of unnecessary Emergency Room visits.

• Reducing the need for in-patient hospital care and institutional care

• Promote independence in the community.

• Eliminate cost shifting between Medicare and Medicaid.

• Achieve cost savings for the State and Federal Government through improvement in care coordination.

LVN/Service Coordinator

May 2014 to March 2015

• Telephone triage and phone reviews for ancillary and LTC services requiring prior authorization for Medicaid members.

• Utilized decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

• Educated members on benefits and qualifications for benefits according to Medicaid status.

• Processing of authorizations or referral of member to correct department or coordinator to provide for their needs.

• Documentation of all processes and actions in TruCare. Clinical Nurse Advisor

Humana

2010 to 2013

• Provided clinical review for outpatient and ancillary services requiring prior authorization for Medicare members.

• Utilized decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.

• Processed all authorizations to completion utilizing appropriate review criteria for Humana product.

• Conducted investigations and reviews of member and provider grievances and appeals.

• Reviewed prospective, concurrent or retrospective medical records of denied services for medical necessity according to Milliman, InterQual, CMS and internal guidelines.

• Determined if care of members will be covered by Medicare using National and Local Coverage Database.

• Extrapolated and summarizes essential medical information for medical director, consultants and other external review.

• Generated appropriate written correspondence in the form of approval or denial letters mailed to providers, members, and regulatory entities.

Education

License in Vocational Nurse Certificate

St Philips College - San Antonio, TX

1996

Skills

Experience using Milliman, InterQual, Amisys, Microsoft Word, Excel, Access, Outlook, TruCare (5 years), Quality Improvement, Quality Assurance, Excel, Microsoft Office Military Service

Branch: USAR

Service Country: United States

Rank: E-5

February 1995 to April 2002

Certifications/Licenses

LVN

July 2017 to July 2018

Additional Information

• Over 21 years of nursing experience to include; Med/Surg, LTAC, Urgent care, Health Coaching with patient education, Utilization review for Medicare and Medicaid, and Service Coordination.

• Familiar with NCD and LCD databases, with a working knowledge of Medicare and Medicaid guidelines.

• Experience using Milliman, InterQual, Amisys, Microsoft Word, Excel, Access, Outlook and TruCare and some knowledge of Prime and Omni 7.

• Knowledge of managed care, referral processes, claims ICD-9 & 10 and CPT coding, and Hedis and STARS Rating System.



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