Nurse Practitioner Management Quality

Jeanette L. Nunes, MSN, FNP, CCM

**** **** **** *** ~ Sacramento, CA 95831 ~ 916-***-**** ~ *********@*****.*** Career Summary:

Family Nurse Practitioner Leader with a diverse set of management and healthcare experience skills including cost containment, medical review of authorizations and claims, quality improvement, concurrent review and case management, with a focus on daily operations, execution of department objectives and HBR Initiatives with measurable interventions and proven results. Looking for an opportunity to advance my skills in a challenging environment. Education:

Psychiatric Mental Health Nurse Practitioner

National University, San Diego, CA April 2021 - Current

Master of Science in Nursing, Family Nurse Practitioner Chamberlain University, Downers Grove, IL May 2017 – February 2020

Bachelor of Science in Nursing

Chamberlain University, Downers Grove, IL October 2015 - November 2016

Associate of Science in Nursing

Sacramento City College, Sacramento, CA August 2010 - May 2012 Experience:

Manager, Health Resources Management

Hill Physicians (PriMed) – Sacramento, California February 2020 – September 2020

Direct daily operations for the Concurrent Review Unit for Medicaid, Medicare, and Commercial teams

Lead clinical team of 25 staff members and oversee health plan services for various different health plans.

Collaborate with various staff from different health plans in order to solidify processes to improve patient health outcomes.

Investigate medical claims, records and other requested information for billing, coding, and other compliance or reimbursement related issues and authorize payment within multiple medical management systems.

Create departmental processes to improve work flow, increase productivity and improve health care outcomes.

Attend weekly rounds to discuss quality improvement measures and implement new processes as needed. Manager, Medical Review Unit

HealthNet (Centene Corporation) – Sacramento, California October 2017 – February 2019

Direct daily operations for the Medical Review Unit for Medicaid, Medicare, and Commercial teams

Leads clinical team of 21 staff members and oversees the management of all members in the state of California

Manage health plan’s HBR initiative for Interest Payment Reduction with a target of 5 million dollars

Developed daily and monthly rollup reports measuring inventory, production, and quality audits

Leveraged actionable data to increase clinical production by 25% across all areas of Medical Review Unit

Resolved backlog of more than 150 million in billed charges for claims and maintained turn-around time

Train staff, manage the workload of the Medical Review Unit and assist with policy and procedure development

Investigate medical claims, records and other requested information for billing, coding, and other compliance or reimbursement related issues and authorize payment within multiple medical management systems

Respond to inquiries and issues from the claims department regarding coding or medical review and appeals.

Oversight of standalone office locations including daily personnel issues, supplies, staffing, and safety

Participate in UM committees and work on special projects related to utilization management as needed

Serve as subject matter expert for clinical and non-clinical staff Senior Concurrent Review Registered Nurse - Lead

California Health & Wellness (Centene Corporation) - Sacramento, California September 2016 – October 2017

Direct daily operations for health plan’s concurrent review team of 19 staff members

Manage health plan’s HBR initiative for IP Redirection and exceeded goal saving over 1 million dollars

Assign team caseloads on a daily basis to manage both production and quality

Oversee weekly and monthly financial audits to ensure authorization accuracy for inpatient validation process

Manage and implement EMR access at targeted hospitals to streamline workflows, and decrease incoming faxes

Conduct quarterly quality audits on staff in accordance with health plan elements to measure compliance

Lead high dollar as well as under and over 21 rounds for concurrent review staff and medical directors

Direct staff inside and outside of department for concurrent review escalations and providing viable solutions

Promote quality and cost effectiveness of medical care by applying clinical criteria and the appropriate application of policies and guidelines to emergent/urgent, continued, and planned stay reviews Jeanette L. Nunes, MSN, FNP, CCM

7343 Farm Dale Way ~ Sacramento, CA 95831 ~ 916-***-**** ~ *********@*****.***

Collaborate with various staff within provider networks and discharge planning team to coordinate member care

Assist with development and refinement of policies and procedures Registered Nurse Care Manager II

California Health & Wellness (Centene Corporation) - Sacramento, California May 2015 - September 2016

Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long-term goals, treatment and provider options

Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes

Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socioeconomic needs of clients

Monitor referrals made to community-based organizations, medical care and other services to support the members’ overall care management plan

Actively participate in integrated team care management rounds and provide feedback and suggestions as needed

Identify related risk management quality concerns and report these scenarios to the appropriate resources via PQI and grievance filing

Direct care to participating network providers; efficient in managing COC in qualified managed Medicaid patients

Participate in case management committees and work on special projects related to case management Registered Nurse Case Manager, Supervisor

Benefit and Risk Management Services, Inc. (BRMS) – Folsom, California March 2014 – May 2015

Responsible for supervising and training all RN and LVN’s in the medical managed care environment while overseeing the nurses’ caseloads and making the appropriate change s to support the business needs

Responsible for supervising five Medical Management Coordinators, one Administrative clerk and one Project Manager to efficiently coordinate care of patients and their needs while ensuring cost containment measures

Authorized research based treatment for approval while issuing denials for experimental treatment. Process physician appeals according to the policy and procedure of the company

Authorize medical services by using medical policy guidelines such as NCCN, MCG, Genex, and InterQual with possible referring requests to a Physician Reviewer

Conducts pre-certification for outpatient, inpatient, concurrent, retrospective and out of network reviews while providing cost containment measures at all times

Documents review information and billing information services; communicates results to claims adjusters

Provide pro-active Large Loss Reports to clients regarding members who are close to meeting their allotted annual specific deductible with researched estimates for potential costs to the plan for the following year Registered Nurse, Staff Nurse III (Progressive Care Unit) San Joaquin General Hospital – French Camp, California July 2013 - March 2014

Provide high quality care to patients with various acute, chronic, and mental health illnesses and interpret EKG recordings

Provide care to patients with wounds, on mechanical ventilation, and patients with tracheostomies, while being responsible to perform all lab draws, and IV starts for multiple patients

Identify irregular telemetry readings and notify appropriate medical team members

Coordinate nursing care with other members of the multidisciplinary team to ensure optimal care of each patient

Educate patients and families how to manage their illness/injury, by explaining post treatment home care needs, diet/nutrition/exercise programs, self-administration of medication and rehabilitation

Record care information concisely, accurately and completely, in a timely manner Licensure and Certifications:

Family Nurse Practitioner, License #95015324

AANP, Certification #F08200484

Registered Nurse, License #822193

CCM through the Commission for Case Manager Certification #4216027

BLS through the American Heart Association

Affiliations:

California Association for Nurse Practitioners

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