DONNA DEFAZIO RN CCM

**** ******** ****. ****. **

St. Petersburg, FL 33714

adibam@r.postjobfree.com

727-***-****

Dedicated Medical Professional with over 35 years of combined nursing experience.

Excellent critical thinking skills, clinical and customer service skills in addition to proficient problem solving capabilities.

Extensive Case management experience evaluating services and needs to meet individual health care plans utilizing planning, communication and resources to promote high quality and efficient care while ensuring cost effective outcomes.

Skill Highlights:

Case Management, Care Management, Medicaid, Medicare, HMO, MMA. Community Care Management, Care Coordinator, Workers Comp, Utilization Review, Phone Triage, Nurse Claim Reviewer, ALF Unit Manager, Sr. Staff nurse, Charge Nurse, Home Health, Skilled Nursing facility, Assisted Living facility and Critical Care Internal Medicine MD office experience.

Professional Experience:

Prestige Health Choice Medicaid

5100 W. Kennedy Blvd. Tampa, FL 33609

IHCM CM II and Community CM RN

Assisted in Developed of Community CM pilot program and primary Community CM

IHCM II RN Telephonic Nurse Case Manager for Prestige Health Choice Medicaid.

Evaluation of member eligibility, assessments, initial and disease specific, behavioral health and social determinants. Care plan development and Health care literacy teaching for successful chronic disease management and health care plan navigation. Provider outreach PCP and Specialty office for effective case management outcomes. Referred and assisted member and providers with LTC application process. Evaluation of social determinants and coordination of local community resources. Launched and developer roles and criteria for Community CM program, screened and targeted local members for community outreach visits in a variety of settings.

May 2015-December 2019

Kepro Medicare QIO

Quality Improvement Organization

5201 W. Kennedy Blvd. Tampa, FL 33609

Medicare Appeals Nurse Reviewer

Determined validity and timeliness of discharge appeal request. Reviewed and summarized medical records for Medical Director determination. Contacted beneficiaries, POA, Health Plans, facilities, LTAC, Acute rehab, SNF, and Hospice providers with appeal outcomes and status.

10/14-5/15

Care Centrix

9119 Corporate Lake Dr. Tampa, FL 33614

Utilization Review of Sleep Management for Cigna Insurance

Reviewed clinical and medical records for criteria and determined eligibility for sleep study request. Approved or elevated to medical review team. Outreach to providers for additional medical record request as indicated.

6/13-9/14

Freedom Health

5420 Bay Center Dr. Tampa, FL

Concurrent Review Nurse and Discharge Planner. Reviewed length of stay guidelines and discharge planning for next level medical appropriateness. Elevation to Medical Director when indicated, approval notifications, denial letter drafting and submission, alerted member, providers, and facilities of outcomes.

12/12 -4/13

Met Life Insurance Co.

Cranes Nest Dr. Tampa, FL

Nurse Care Manager LTC Determination

Reviewed individual insurance policies and criteria for member benefit eligibility. Contacted members, care givers, providers, facilities and Home Health companies for additional clinical documentation to support request. Submitted referrals for onsite assessments, processed approvals and notified denial department per case review.

7/12-12/12

Community Health Solutions of America South Carolina Medicaid

118th Ave N. St. Petersburg, FL 33716

Phone Triage Nurse, Claim reviewer, Disease and Case Management referrals. Resolved pharmacy issues, provided care coordination, provider and Community Resource referrals.

4/10 - 7/12

American Nurses

US 19 N., Pinellas Park, FL

Home Health Nurse, Diabetic and Disease Management, Pt. education, Wound care, physical assessments, medication management, direct MD communication and care coordination.

5/2005 - 9/2011

CSI Catalono's Nursing Registry

East Bay Dr. Clearwater, FL

Private Duty and Home Healthcare visits.

Disease Education, wound care, medication and treatment management.

11/07 - 4/10

Lodge of Mainland’s, ALF

US 19 N., Pinellas Park FL

ALF Clinical Nurse, Diabetic management, Quarterly Summaries, MD and Home Health coordination.

Alzheimer Unit Mgr. Unit Reorganization, staff interviewing and hiring. Directed clinical and social service staff. Lead local chapter of National Alzheimer organization support group monthly.

2005-2006

Dr. Wayne Garcia

Internal Medicine/Critical Care

Pasadena Ave, Pasadena FL

Back Office Nurse, phone triage, Pt. assessments, BP and Coumadin clinic, assisted with procedures, obtained updated clinical information, medical histories, diagnostic findings, lab results.

2000-2002, 2004, 2006

Nurses Choice

4th St. N. St. Petersburg, FL

Skilled Nursing Facility staff relief all shifts Supervision, documentation, medication administration, assessments, treatments, lab results MD, Pt. family communication.

2000-2002

Community Care Network

Faulkenburg Rd. Brandon, FL

Precertification Workers Compensation AIG Insurance Co. Determination of medical necessity for treatments, surgery and therapy requests related to worker's compensation injuries.

1997-1998

Travelers Insurance Company

W. Kennedy Blvd. Tampa, FL

Utilization Review Assistant Case Manager Workers Compensation.

Determination of medical necessity for treatments, surgery, therapy request, followed work injury to MMI status.

1996-1997

Bay Pines Veterans Administration

Bay Pines Blvd. Bay Pines FL

Nursing Home Care Unit-E. Direct patient care, documentation, medication and treatment administration.

1995-1996

Skills:

Telephonic, computer skills, Customer service applications, Microsoft office, Consensus, Excel, Lotus Notes, Iiaka, Interqual, JIVA

Education:

LPN Program Feb. 1985 Orlando Vocational Technical Ctr

RN Program Aug. 2014 Fortis College Largo, FL. with Transfer to Suncoast College of Health. Formerly SFTI Bradenton FL.

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