Case Manager Customer Service

SUSAN L. HODGE, RN, BSN

*** ******* **., ************, ** 37659 cell phone: 423-***-****

**********@*****.***

Professional Summary

Licensed Registered Nurse, with a Bachelor of Science in Nursing degree. Accountable for promoting interdependent collaboration with the member, physician/primary care manager, family and other members of the health care or case management team. Duties include assessment, implementation, monitoring and evaluating available resources in an effort to promote quality, cost-effective outcomes while meeting the individual’s health needs. Also identifying appropriate providers and facilities in an effort to improve or maintain the social, emotional, functional and physical health status of the client, as well as enhancing the coping skills of the family or other caregiver. Previously worked as catastrophic case manager with responsibility for the collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. Worked in the health care insurance industry preparing and writing service denial communications relating to TennCare/Medicaid insurance. Understand state regulations and contractual requirements relating to TennCare CMS and Medicaid, meeting regulatory requirements at local, state and federal levels. Knowledge of TennCare CHOICES program including HCBS but not limited to eligibility, services and rules.

Skills Highlights

--all jobs included all of the skills below

Medicare/Medicaid service denial

communications

Health insurance regulations

Medical terminology and physiology

Health industry knowledge

Milliman Guidelines

Interqual Guidelines

TennCare/Medicaid regulations

TennCare/Medicaid compliance

Health Edge program

CMS guidelines

Source program

Medimpact

Knowledge of patient billing

CareOne patient care program

Facets billing information program

Pharmacy experience

Adaptable to change

Strong organizational skills

Problem solving

Customer service excellence

Work Experience

Life Care Center of Gray SNF—Medical Case Manager/RN 02/2022- present

Ballad Health Case Manager –Medical Case Manager 10/2021- 01/2022 Johnson City, TN

BlueCross BlueShield of Tennessee – Medical Case Manager, 10/2016 – 10/2021 Johnson City, TN

Ballad Health - ISHN/CrestPoint Health - Catastrophic Case Manager, 09/2015-10/2016 Johnson City, TN

UnitedHealthcare Group - Senior Clinical Administrative Nurse, RN, 01/2010-09/2015 Kingsport, TN

UnitedHealthcare Group - Medical Utilization Review, RN, 01/2007-01/2010 Kingsport, TN

ETSU Physicians and Associates, Kingsport, TN - Clinical Registered Nurse, concentrating in infusion therapy for rheumatology, 07/2006-01/2007

ETSU Physicians and Associates, Johnson City, TN - Clinical Registered Nurse, working with internal medicine physicians, 07/2006-01//2007

License and Certifications

State of Tennessee Nursing License, RN0000057379

American Heart Association, BLS for Healthcare Providers Program (CPR and AED)

Certified Case Manager 2019

College Education

University of Florida 1977-1979 Associates Degree Gainesville, Florida

University of South Alabama 1979- 1981 Bachelor of Science in Nursing Mobile, Alabama

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