Registered Nurse Manager
Resume:
ALEXIS JAMES, BSN, RN
***** ******** ****** **, *********, FL 33579
********.**@*****.***
SUMMARY OF QUALIFICATIONS
Compassionate and dedicated Registered Nurse seeking to expand nursing experience. Well-regarded skills in providing optimum patient care. Self-directed, highly motivated and eager to accept new challenges.
SKILLS
●9 years of insurance managed care experience.
●9 years of inpatient Acute Care UM/UR experience.
●9 years of Millman/Interqual program experience.
●10 years acute rehab/skilled Nursing Facility experience.
●Critical thinking skills essential to providing competent and dignified patient care.
●Extensive multi-tasking, problem solving, communication skills and organizational skills.
EMPLOYMENT HISTORY
June 2019 Special Matter Expert (SME) (Regional)
Aetna, Tampa, FL
SME reviewer for all approvals/denials for all Medicaid, Medicare, and Commercial medical necessity reviews according to CMS guidelines.
Determines appropriate levels of coverage for inpatient stay by using clinical judgment and applying nationally recognized criteria including Milliman Care Guidelines to meet the member's needs.
Sept 2017-June 2019 UM NURSE CONSULTANT (Mid-South)
Aetna, Tampa, FL
Utilizing clinical skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options and services to facilitate appropriate inpatient healthcare management and effective discharge planning to improve the outcomes for members.
Obtaining necessary information from providers and facilities; assessment of a member's clinical condition and ongoing medical services and treatments to determine medical appropriateness; guide the setting for medical intervention to achieve optimum length of stay for members.
Authorize and coordinate the required services, in accordance with the benefit plan for SNF, Acute rehab, and LTACH.
Determines appropriate levels of coverage for inpatient stay by using clinical judgment and applying nationally recognized criteria including Milliman Care Guidelines to meet the member's needs.
2018-2019 REGISTERED NURSE- (Weekend Supv)
Addington Place at College Harbor, St. Petersburg, FL
Knowledgeable of resident rights and ensures an atmosphere which allows for the privacy, dignity and well-being of all residents in a safe, secure environment
Supports and cooperates with specific procedures and programs for:
Safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs
Confidentiality of all data including resident, employee and operations data
Quality Improvement and compliance with all regulatory requirements
Compliance with current law and policy to provide a work environment free from sexual harassment and all illegal discriminatory behavior
Supports and participates in common teamwork:
Cooperates and works together with all co-workers
Uses tactful, appropriate communications in sensitive and emotional situations
Follows up as appropriate with supervisor, co-workers or residents regarding reported complaints, problems and concerns, fills out grievance reports as indicated.
2014-2018 REGISTERED NURSE-PRN
Addington Place at College Harbor SNF, St. Petersburg, FL
●Perform physical assessments, administer medications / IV fluids, and monitor recovery process. Track lab values and test results, updating physicians when appropriate. Operating IV lines; Foley catheters, nasogastric (NG) feeding tubes; wound care and dressing changes including wound-vacs; PICC/Central line maintenance and care; Monitor intake and output.
2016-2017 UTILIZATION MANAGEMENT CLINICIAN
Health Integrated, Tampa, FL
Utilizes clinical experience and skills in a collaborative process to assess, plan implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for CHPW members
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
Maintains a thorough understanding of URAC Accreditation Guidelines for Utilization Management.
Adheres to the plans HIPAA and privacy standards and confidentiality agreement.
2014-2016 NURSE MEDICAL MANAGEMENT-UTILIZATION
Amerigroup, Tampa, FL
Utilizes clinical experience and skills in a collaborative process to assess, plan implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
Maintains a thorough understanding of URAC Accreditation Guidelines for Utilization Management.
Adheres to the plans HIPAA and privacy standards and confidentiality agreement.
2013-2014 REGISTERED NURSE/ PRE-AUTHORIZATION
Coventry Health Care, Tampa, FL
●Performed prior authorization and retrospective review according to Interqual Criteria, Medicare Guidelines and established protocols to determine the medical appropriateness of request.
●Refers cases to Medical Director when the treatment request does not meet medical necessity guidelines or when a peer-to-peer conversation is necessary to establish appropriateness.
●Maintains a thorough understanding of URAC Accreditation Guidelines for Utilization Management.
●Adheres to the Plan’s HIPAA and Privacy Standards and Confidentiality Agreement.
●Identifies problems or complex cases and refers for possible case management intervention and identifies patients with chronic disease process for possible disease management intervention.
2014-2018 REGISTERED NURSE-PRN
Allegro at College Harbor SNF, St. Petersburg, FL
●Perform physical assessments, administer medications / IV fluids, and monitor recovery process. Track lab values and test results, updating physicians when appropriate. Operating IV lines; Foley catheters, nasogastric (NG) feeding tubes; wound care and dressing changes including wound-vacs; PICC/Central line maintenance and care; Monitor intake and output.
2013 REGISTERED NURSE-PRN
Tierra Pines killed facility Largo, FL
●Perform physical assessments, administer medications / IV fluids, and monitor recovery process. Track lab values and test results, updating physicians when appropriate. Operate and insert IV lines; Foley catheters, nasogastric (NG) feeding tubes; wound care and dressing changes including wound-vacs; PICC/Central line maintenance and care; TPN and blood transfusions according to proper procedures. Monitor intake and output. Direct care of 25 patients for a 50-bed unit. Stage wounds and implemented standard skin orders per facility policy.
2011-2013 REGISTERED NURSE / CASE & DISEASE MANAGER/ SPECIAL NEEDS PROGRAM CASE MANAGER
Universal Health Care, St. Petersburg, FL
●Act as a patient advocate and identify members with unmet healthcare needs who may be at risk for hospital admission or readmission.
●Assess and manage readmission risk related to targeted chronic/serious disease
●Review hospital admissions using Fortuna guidelines
●Provide admission counseling to members as well as post-discharge calls, focusing on discharge instructions and post hospital needs.
●Communicate with members and providers via telephone to assess the quality and appropriateness of care
●Monitor daily biometric device data for Heart Failure and COPD member programs
●Assist members in better managing their Heart Failure/COPD/Asthma diagnosis by providing ongoing education and support
2011-2013 REGISTERED NURSE/Unit Manager
Nuvista Post-Acute Care Center, Lutz, FL
●Transitional care support nurse, who maintained the daily admissions to the unit on average of 5-6 admission a day, calling of physicians, and order entry of physician orders.
●Perform physical assessments, administer medications / IV fluids, and monitor recovery process. Track lab values and test results, updating physicians when appropriate. Operate and insert IV lines; Foley catheters, nasogastric (NG) feeding tubes; wound care and dressing changes including wound-vacs; PICC/Central line maintenance and care; TPN and blood transfusions according to proper procedures. Monitor intake and output.
●Duties of a TCSN were to assist floor rehab RN’s and LPN’s in management of the direct care of 25 patients for a 50-bed unit. Stage wounds and implemented standard skin orders per facility policy.
2011 Registered Nurse/Unit manager
Alhambra health & Rehabilitation Center, St. Petersburg, Fl
●Direct report to the Administrator and DON about day-to-day supervision of licensed and non-licensed personnel and the patients on the unit.
●Chart reviewing, reviewing COC patients 24hrs status to discuss in department heads meeting.
●Participated in the interviewing and hiring/firing of nursing personnel on unit. Insured proper staffing of nursing staff on unit also assist the floor nurses with patient care when coverage was not available worked as a floor nurse.
●Involved in QA, MDS, case management of patients throughout the facility. Made 1st line decision regarding to patients and nursing staff.
2008-2011 LICENSED PRACTICAL NURSE
West Minister Palms, St. Petersburg, FL
Provided direct nursing care to 15-20 geriatric skilled nursing patients within a skilled nursing unit.
●Was under direct supervision of a RN, my responsibilities include working directly with patients, giving injections, vital signs, performing basic diagnostic tests, dressing wounds, and administering medication.
●Operate and insert Foley catheters, nasogastric (NG) feeding tubes; wound care and dressing changes
●Monitor intake and output. Act as patient advocate, assess patient status and notify physicians of clinical changes.
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2008-2009 LICENSED PRACTICAL NURSE/CORRECTIONAL NURSE
Maxim Healthcare Agency, Tampa, FL
●My responsibilities include daily Accu checks, slight management of wound care and medication administration to roughly 200 inmates daily.
CERTIFICATIONS / LICENSES
●Florida Registered Nurse - License #9328987
●BCLS Certification & CPR Certification - American Heart
EDUCATION
Walden University
MSN-Currently enrolled
St. Petersburg College, St. Petersburg, Florida
Bachelors of Science-Nursing
St. Petersburg College, St. Petersburg, Florida
RN / Associate of Science in Nursing
Galen School of Nursing, St. Petersburg, Florida
Licensed Practical Nurse
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