AMBER DARBY, RN

**** ********* ****** *********, ** 95688 · 707-***-****

adqto9@r.postjobfree.com

I am a dedicated hardworking Registered Nurse with over 15 years of diverse healthcare experience. Currently, seeking a nursing career in Case Management and/or Utilization Coordination to further expand my experience while providing quality healthcare to clients in need. EXPERIENCE

A-LINE STAFFING

APPEALS NURSE-G&A-UM

MARCH 2021- CURRENT

• Perform retrospective review of large hospital and physician claims for admission appropriateness, coding, length of stay, and pricing and review retrospective medical necessity appeals against medical review criteria to make benefit determinations.

• Assist with other clinical functions of medical review.

• Maintain appropriate records, files, documentation, etc. ANTHEM

NURSE MEDICAL MANAGEMENT, I

APRIL 2018-MARCH 2021

• Process LOI/Pend cases as assigned by daily assignment.

• Process callout cases for verbal notification to provider on authorized cases.

• Filters specific task lists to ensure cases are ready for nurse review (Sweep)

• Meet a minimum Monthly Quality expectation of 93% or better on monthly audit. PARTNERSHIP HEALTH PLAN OF CALIFORNIA

Inpatient Nurse Coordinator

October 2015 – September 2017

• Managing Acute, Skilled Nursing, Short-Term Rehab, and Long-Term Rehab admissions for two of the largest capped and non-capped facilities in Solano County.

• Maintaining utilization reviews, authorization, denials, and lower level of care admissions for clients receiving acute care.

• Prior-authorizations for out-patient procedures, such as, pain management, home health, DME, MRI’s, dialysis, tertiary transfers, ect.

• Participating in HEDIS preparations for 2018 certification.

• Lead nurse in our discharge team that screens, collects, tracks, and analyzes data of clients who are high risk of re-admission and/or emergency room visits.

• Implemented and developed with department head desktop procedures that effectively decreased errors and increased productivity. 2

• Participated in the development of a software program that integrated three departments into one program that provided a 360 view of each client. PATHFINDERS HOME HEALTH

CLINICAL NURSE

JANUARY 2014 - JUNE 2015

• Planning and implementing skilled out-patient services

• Blood sugar checks, blood draws, PT/PTT blood check, foley catheter change and med reconciliations

• Assessing home environment and basic needs to ensure client safety and emotional needs.

• Completing wound care and assessing for change of condition. ELMCROFT ASSISTED LIVING

ASSISTANT DIRECTOR OF NURSING

OCTOBER 2011 - JANUARY 2014

• Supervising and training staff to ensure procedures and guidelines were being followed to ensure client safety.

• Initiated MD orders and effectively transcribe and communicated Medical Administration Records appropriately.

• Directed staff meetings to introduce and maintain current guideline, policies and procedures.

NORTHBAY MEDICAL CENTER

UTILIZATION COORDINATOR

JULY 2008 – JUNE 2011

• Analyzed patient records to determine legitimacy of admissions, treatment, and length of stay in an acute care facility to comply with Medicare/Medi-Cal and health plan guidelines.

• Responsible for assessments, continued reviews, and coordination of discharge planning activities.

EDUCATION

MAY 2015

ASSOCIATE DEGREE IN NURSING, LONE STAR COMMUNITIY COLLEGE SKILLS

• Excellent leadership, communication, and

interpersonal skills

• Organizes multiple priorities with ease and uses downtime effectively

• Utilized knowledge of CPT, ICD 10 and ICD 9 codes.

• Tech Skills: Advanced user of ACMP, OMPTA, CCB,

Milliman and Interqual criteria, Cerner and Epic EHR, and Microsoft Excel and Outlook.

• Additional experience and knowledge in Home

Health, Management, California Children

Services, and HEDIS.

• Detailed oriented and uniquely organized

• Creative thought process

• Manages time well by continuously evaluating

current methods to improve quality and

production.

• Loyal and collaborative team player

3

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