JAMES E. CARTER

**** **** ****** ****** ********, AL 35022 205-***-**** or 205-***-****

adn9zg@r.postjobfree.com

PROFESSIONAL EXPERIENCE

Licensed Practical Nurse, 2020 - Present

Amedisys Home Health

Provide quality patient care and performing technical skilled care in the patient's home.

Educate patients and caregivers of patient care and medications.

Communicate with patient physicians as needed to provide optimal patient care in the home.

Collaborate with other healthcare disciplines.

Clinical Account Executive, 2019 – 2020

LHC Group / Central Alabama Home Care

Coordinates the referral of patients to home, ensuring that patient choice of the home care services is honored.

Evaluates patients’ suitability for home health upon request from the physician / facility.

Receives referrals from the physician / facility assigned and sends to the appropriate branch of the home health agency

Act as a liaison between the patient / caregiver and the physician and the home health agency.

Schedules and coordinates physician follow up appointments when appropriate.

Receives patient reports from the agency field staff and communicates those reports directly to the physician / nurse.

Responsible for executing sales strategy of accounts to increase company market share through development and education.

Follow up to ensure that the original order is mailed or delivered to the home health agency.

Facilitates obtaining the proper physician documentation to meet the home health face to face encounter requirement.

Licensed Practical Nurse, 2018 – 2019

Central Alabama Home Care

Provide quality patient care and performing technical skilled care in the patient's home.

Educate patients and caregivers of patient care and medications.

Communicate with patient physicians as needed to provide optimal patient care in the home.

Collaborate with other healthcare disciplines.

Licensed Practical Nurse, Manager 2017 – 2018

Danberry at Inverness, Birmingham, AL

Supervise residential assistants, dispense medications, provide care of geriatric residents.

Communicates with resident sponsors as needed as well as collaborated with physicians of patient services.

Writes and submits reportable incidents to Alabama Department of Public Health.

Resident Care Coordinator/Administrator 2016 – 2017

Noland Health Services, McCalla, AL

Perform administrative duties such as completing medical forms, reports, evaluations, charting, etc. as necessary.

Coordinate scheduling of resident care personal.

Transcribe physician’s orders to resident charts, medication administration records, treatment/care plans.

Perform audits and maintain information relating to quality assurance.

Perform employee performance evaluations and make recommendations concerning employee disciplinary action.

Participate in facility surveys(inspections) made by authorized government agencies as needed.

Manage day to day operations ensuring the building meets state criteria for assistant living.

Participates in staff development programs and staff meetings.

Follow appropriate OSHA, CDC, state, and federal regulations and organizational policies.

Writes and submits reportable incidents to Alabama Department of Public Health.

Licensed Practical Nurse Manager 2016 - 2016

Oaks on Parkwood/Noland Health Service, Bessemer, AL

Supervise residential assistants, dispense medications, provide care of geriatric residents.

Communicates with resident sponsors as needed as well as collaborated with physicians of patient services.

Promoted Resident Care Coordinator/Administrator.

Licensed Practical Nurse Manager 2015 – 2016 (Part-time)

Chandler Nursing Home, Alabaster, AL

PROFESSIONAL EXPERIENCE (continue)

Supervise residential assistants, dispense medications, provide care of geriatric residents.

Communicates with resident sponsors as needed as well as collaborated with physicians of patient services.

Licensed Practical Nurse Manager 2012 - 2015

LAKEVIEW ESTATES, FIVE STAR QUALITY SENIOR LIVING, BIRMINGHAM, AL

Supervise residential assistants, dispense medications, provide patient care of geriatric residents.

Communicates with resident sponsors as needed as well as collaborated with physicians of patient services.

Licensed Practical Nurse Manager 2011 - 2012

FAIRFIELD NURSING & REHABILITATION, FAIRFIELD, AL

Dispense medications, provide patient care of geriatric residents.

Assist with rehabilitation of short term residents as well as transcribes physician orders.

Communicates with resident sponsors as needed as well as supervise nursing aides and assistants.

Clinical Care Coordinator/Assistant Health Services Director 2011 - December 2011

PROGRESSIVE HEALTHCARE PROVIDERS OF ALABAMA, BIRMINGHAM, AL

Managed staff by establishing priorities, assign and review work and resolve issues in all settings including, clinical, and service sites.

Interviewed and selected individuals for open positions in the clinical area.

Assessed and reviewed each individual medical condition.

Assisted in development of Individual Support Plan (ISP) in nursing capacity.

Consulted and collaborated with physicians and clinical staff of patient services.

Determined and participated in implementing appropriate action, treatment, response and follow-up care needed through resolution, via Nursing Care Plan as identified in the ISP.

Participated in admission/discharge review process.

Trained/educated staff of medication administration and assisting residents in ADL”s, self-administration of medication, first aid, health care and human awareness including administer medications and treatments as ordered.

Implemented facility personnel orientation.

Served as Acting Health Services Director in that person’s absence.

Attended incident management committee meetings and provide relevant information.

Monitored medication administration system to ensure continuity and quality.

Available “on-call” via cell phone as needed to coordinate after-hours health related services.

Arranged and coordinated out sourced pharmacy services according to the needs of individual ISP.

Key Contribution & Achievements:

Coordinated the care of 27 newly acquired residents over a period of 30 days including scheduling medical appointments, administration of medication, recreation activities, and social work collaboration.

Streamlined the intake process of residents.

Licensed Practical Nurse Manager/Part-time 2010 - 2011

LEGACY HEALTH & REHABILITATION, LLC, PLEASANT GROVE, AL

Dispense medications, patient care of geriatric residents.

Assist with rehabilitation of short term residents as well as transcribes physician orders and supervise nursing assistants.

Communicates with resident sponsors as needed as well as supervise nursing aides and assistants.

Benefit Integrity Investigator II/Project Manager - 2004 - 2010

CAHABA SAFEGUARD ADMINISTRATORS, LLC/Subsidiary of Blue Cross Blue Shield, BIRMINGHAM, AL

Reviewed, analyzed, and developed allegations of fraud and abuse against the Medicare Trust Fund in accordance with regulatory guidelines of compliance set forth by the Centers for Medicare & Medicaid Services (CMS).

Proactively worked a caseload for possible referral to external governmental agencies for further investigation or prosecution.

Researched Medicare guidelines and policies of state, and federal laws.

Actively communicated with law enforcement, CMS, Department of Justice DOJ task force member, medical providers, beneficiaries, Medicare Fair Hearings and Administrative Law Judges on a regular basis.

Provided oral and written presentations or briefings.

Analyzed data & medical records for case development in a multi-state jurisdiction with multiple benefit structures.

Performed onsite audits of integrity of medical provider’s claims and accounting practices.

Interviewed subjects, complainants, and witnesses to gather and evaluate evidence for case development.

PROFESSIONAL EXPERIENCE (continue)

Presented statistical data to law enforcement, DOJ task force, Meta-Analysis team and management of case development.

Coordinated the development of Meta Analysis team approach to address the needs of project development.

Key Contributions & Achievements:

Promoted to Benefit Integrity Investigator II after 6 months of service.

Developed work flow sheet for department distribution.

Direct, organize and coordinate onsite audits to Georgia, Mississippi, and Alabama.

Various cases lead to prosecution or reimbursement to the Medicare trust fund.

Developed workflow sheet for departmental distribution.

Created crosswalks and screen layouts with program specifications to create and revise operational workload, policies and procedures.

Selected to serve on local DOJ taskforce to provide solutions for Medicare fraud.

Network Account Manager 1999 - 2004

UNITED HEALTHCARE, INC., BIRMINGHAM, AL

Negotiated fee-for-service HMO hospital and ancillary contracts.

Performed cost per unit analysis, including managing accounts in the areas of customer service, provider relations, and claims administration.

Facilitated meetings with providers to train staff on complex Medicare reimbursement policies.

Monitored provider activities to ensure contract compliance.

Initiated sanctioning procedures against physicians when appropriate.

Key Contributions & Achievements:

Negotiated contracts with skilled nursing homes, physicians, and hospitals.

Recruited for top-grade position as Network Account Manager during re-organization.

Metra Health Consumer Affairs Associate/Interim Supervisor 1997 - 1999

UNITED HEALTHCARE, INC., BIRMINGHAM, AL

Reviewed and resolved all matters involving appeals from physicians.

Researched members’ complaints provided resolutions and updated claims.

Performed duties of interim supervisor, including assisting with hiring process.

Chaired weekly (1st level complaints) and bi-monthly (2nd & final internal level complaints) Consumer Affairs Review Committees.

Responded to complaints to the Department of Insurance and reported employee concerns to upper-level management.

Key Contributions & Achievements:

Identified process improvement and quality issues from a medical and business perspective.

Communicated with upper management and implemented policies and procedures of department to staff.

EDUCATION

UNIVERSITY OF ALABAMA BIRMINGHAM, BIRMINGHAM, AL

Bachelor of Science in Allied Healthcare Administration

Internship: Quality Assurance Administrator at Jefferson County Department of Health

LAWSON STATE/BESSEMER TECHNICAL COLLEGE, BESSEMER, AL

Diploma in Licensed Practical Nurse

ALABAMA ASSISTANT LIVING ADMINISTRATOR LICENSE 2016

CERTIFICATION: MAS - MEDICATION ASSISTANT SUPERVISOR CERTIFICATION 2011

Certificate: 1CD-10 CM 2016

PROFESSIONAL MEMBERSHIPS

American Association of Managed Care Nurses, Association of Certified Fraud Examiners, and National Health Care Anti-Fraud, Community Health Advisor (CHA)- UAB Diabetes Research & Training Center and Minority Health & Health Disparities Research Center 2010, LDA-Leadership Development Association-Member. COMPUTER SKILLS Proficient in Microsoft Office, AIT Charting Systems, LEXUS NEXUS, COWS, FID, MCS, CPT Coding skills, Risk Adjustment Code Training, MARS medication systems.

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