Utilization Review Nurse Consultant
Resume:
Anne M. Jones
H) 706-***-****
adrtb1@r.postjobfree.com
North Augusta, SC 29841
History of Employment
June 2015-Present, PRN Utilization Review Case Manager (every other weekend) HCA Doctors Hospital Augusta GA
- Utilization review of all hospital admissions for appropriate level of care and status (inpatient, observation, outpatient) including commercial insured, Medicare, Medicaid and unfunded using Interqual clinical criteria.
-Perform as charge reviewer when needed.
-Participate in Discharge planning and documentation, patient/family interviews, collaborate with providers and other interdisciplinary team members.
- Perform as charge CM when needed.
July 2020-Present, Burn and Reconstructive Centers of America, Clinical Quality Improvement Coordinator
-Responsible for assisting in the development of a meaningful and measur-
able platform for Burn and Reconstructive Centers of America.
-Coordinates, collaborates, and acts as a liaison with insurers, affiliate
Hospitals, physicians, clinical staff, quality team and billing to develop
and maintain quality measures as requested by leadership.
-Maintain a knowledge of regulatory guidelines and requirements for quality measure reporting.
-Review CMS clinical quality measure specifications and assist in determining measures to be reported to CMS.
-Act as a liaison between clinical staff/quality/billing
-Abstract quality data from patient charts/EHR/Meditech and enter in data registry.
-Monitor quality performance dashboard and identify issues and assist in education efforts.
-Assist in identifying and developing changes in workflow or processes to help meet quality goals.
-Identify our standard burn care practices that are measurable and have potential for quality measure development.
- Assist in developing a process to ensure chronic conditions are documented and billed when appropriate.
-Comply with all safety policies, practices, and procedures. Report all unsafe activities to supervisor and/or Human Resources.
Participate in proactive team efforts to achieve departmental and company goals.
-Perform other duties as assigned.
Provide leadership to others through example and sharing of knowledge/skill.
Participate in education sessions specific to corporate needs or job duties – locally or remotely, as needed.
Provide training to other employees – locally or remotely, as needed.
March 2018-July 2020 Augusta University; Value-Based Care Coordinator
-Serve as a liaison between the Adult Practice Site Coordinators, Nursing Leads, and the Population Health team on coordinating care for those patients who are identified as high risk, frequent flyers, or low compliance.
-Partners with the Chief Quality Officer and Director of Population Health on determining which specific patient population need to be focused on that will results in a reduction of cost and improvement of quality outcomes.
-Will coordinate directly with the Patient Outcome RN within the Ambulatory care setting to ensure improvement is being made for those patients while in the care setting.
-Works directly with the patient’s primary care provider on barriers, issues, or concerns for the patient. Will help set patient goals and health concerns in conjunction with the patient’s care team.
-Will help to direct this specific patient population from over utilization of resources such as the Emergency Department by helping to coordinate needed appointments with the patient’s primary care provider or care team.
-Assist the Practice Site Coordinators and the Care Coordination team in specific departments to close care gaps and care opportunities for a specific patient population to improve and enhance clinical quality care.
-Works with the applicable Practice Site Coordinators and other clinical staff members to ensure that clinical guidelines are being met consistently that are related to chronic disease management
-Provide clinical insight to the applicable providers, care teams, and service lines each month on reports for the specific patient population on outcomes and cost reduction.
-Works with the Care Gap Assessment Coordinators to understand the opportunities for improvement for the specific patient population around patient outcomes.
-Provides disease management support to the specific patient population within the AU Health population.
-Works with health professionals, including providers, in the practice setting to assist with coordinating care for each patient identified.
-Will work directly with the Ambulatory Educators to provide resources and contacts for the patient with a specific chronic condition.
-Must be able to communicate effectively with providers, administration, and nursing team to ensure a team-based approach is provided for this specific patient population.
-Will have interactions with the following team or staff members: Coding Department, Billing Coordinators, Ambulatory Outpatient Nursing leadership, Inpatient nursing leadership, Jaguar Collaboration team members, Practice Site Administrators, and Practice Site Coordinators.
January 2014- March 2018 Humana Inc; Onsite Clinical Advisor/Utilization management of Southeast Region, Health Services Organization (remote)
-Conduct admission Utilization Review for acute admission, rehab admissions and Skilled nursing placements using Milliman clinical criteria. Participate in peer-to-peer reviews, denials and secondary reviews.
-Conduct onsite interview with Humana member while inpatient for assessment of care, discharge needs, advocate patient services.
-Coordinate with the interdisciplinary team at Onsite facility to help with Humana Managed Medicare patients as well as education in the authorization process and discharge process.
-Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using knowledge of benefit plan design
-Recommend services for Humana Plan members utilizing care alternatives available within the community and nationally
-Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols
-Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria
August 2013-Jan 2014 Clinical Nurse Advisor/Utilization management; WellCare (remote)
-Conduct Utilization Review of acute admissions using Interqual clinical criteria. Participate in peer-to-peer reviews, denials and secondary reviews.
-Coordinate with the interdisciplinary team at the facility to help with WellCare Managed Medicare patients as well as education in the authorization process and discharge process.
-Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using knowledge of benefit plan design
-Recommend services for WellCare Plan members utilizing care alternatives available within the community and nationally
-Identify potentially unnecessary services and care delivery settings. Recommend alternatives as appropriate.
August 2007- Augusta 2013 Managed Care Eisenhower Army Medical Center; Consult Utilization Review Management/ Managed Care Administrative Nurse
-Provide clinical expertise in the management & delivery of health care plans, direct, coordinate, manage, monitor, and evaluate the appropriate level of care by reviewing referrals, health care plans and historical care provided.
-Review, monitor, implement, and facilitate achievement of quality care, appropriate care costing and clinical outcomes by referring to the most appropriate clinical setting.
-Redirect/recapture of referrals to retain care w/in the Military Tx facility as clinically appropriate.
-Function as the clinical liaison with physicians in interpretation/implementation of guideline and criteria for patient care according to the anticipated outcomes according to the DOD, Interqual, ICD-9, CPT, DSM & Milliman Ambulatory Guidelines.
-Proficient in the system use of window, excel, mods, chcs, ahlta, word and mebitts.
-Knowledgeable of the networking area within EAMC and the local Tri Augusta Area and the resources needed to obtain information from network providers and facilities within a timely manner. Establish contacts in place both civilian and military for timely receipt of clinical information.
-Provide knowledge of utilization of discharge planning, disease management and quality management to improve access and provide quality, cost effective healthcare both in the military/civilian health care system.
-Assist in orienting, training physicians and ancillary personnel in the referral management process.
-Work closely w/ Tri-care and Health Benefits to support Service members and their dependents in the continuum of health care.
development in policies and procedures as assigned.
-Acutely aware of Army policies and regulation to include but not limited to IAW AR 40-501.
-Comprehensive knowledge of Federal, DOD, Personnel Management.
June 2005 –August 2007 Eisenhower Army Medical Center Ft. Gordon, GA Case Manager * Lead Nurse Consultant
-Comprehensive Utilization Review and Management, Case Management while providing comprehensive Leadership.
-Provide professional scope of practice for a variety of medical / surgical / behavioral health/ diagnoses with individual primary care focused case management by planning, developing, discharge planning, directing, and coordinating administrative, personnel and management services while ensuring cost effective services.
-Supervision of Case Managers within Alpha Company to maintain good working relationships; review, advise, analyze, and evaluate individual case managers.
-Coordinate and implement plans of care Tricare Prime, Standard, Regional and Medicare patients, Soldiers, and their families.
-Client assessments not limited to but to include identifying holistic needs. Conduct in-depth assessment of functional status, occupational hazards, acuity level, and prognosis as well as assessing and implementing the need for treatment services and resources.
-Coordinating/collaborating with attending Physicians while also ensuring a multidisciplinary approach to cost effective, quality care and utilization of resources within the USA MEDCEN and network providers as indicate, to assure complete provision of care for clients.
-Education of clients in areas of preventive health information, worksite hazards and occupational health programs.
-Coordinate, collaborate and serve as a Lead Case Manager to ensure accountability of team operations to provide support, coordination of care and guidance for the Service member and leadership of a Service Member with the Co. Commanders, Squad Leaders and the Platoon Sergeant on a weekly basis and as needed.
-Serve as the Service Members advocate and liaison within the health care team, community, and family network.
-Document all plans, assessments and care provided in a timely manner and according to policy and regulation.
-Guide and monitor discharge planning from the initial intake and assessment with the focus on the needs of each individual Service Member.
-Proficient knowledge of ICD-9 coding and Inter-qual.
-Monitor delivery of services provided by network civilian contracted vendors and VAMC, to ensure quality delivery of care to military service members and their families within the Tricare access to standards of care.
-Ensure and monitor adherence to the access of care standards within DDAMC.
-Provide timely referrals to social services, TRICARE benefits liaison, and Veterans Affairs Representatives along with Specialty care providers.
-Responsible for tracking and reporting internal tracking log for timelines by the Surgeon General’s standards.
-Responsible for implementation, guidance, and supervision of the WTB Nursing staff to ensure that all policies and procedures are being followed as set forth by the 1st Army, Ft. Gordon MEDCEN, DA, OTSG, MEDCOM and SERMC.
-Provide precise WTB Nurse Case Management orientation for new employees and serve as a mentor for other Nurse Case Managers.
-Address, identify and correct any area of improvement as noted to ensure quality cost-effective health care for each Service Member, to ensure a positive experience and outcome.
-Responsible for ongoing professional medical case management development, training, and evaluation of professional and administrative staff members, while incorporating the WTB staff and Officers. Continuing education includes but not limited to the unit standards, protocols, medical education, and quality improvement with the focus being on the outcome and care of the WTB Service Member.
-Monitor and evaluate for appropriate plans of care as established by individual Case Mangers within the WTB to ensure timely and appropriate care while providing positive feedback and communication.
-Coordinate and arrange vacation and leave time for Service Members and the WTB Nurse Case Managers.
-Implementation of quality assurance and peer review interventions.
March 2004 – June 2005 Medical College of Georgia; Neonatal Intensive Care Unit Senior Staff Nurse
-Perform duties consistent with senior NICU staff nurse job description in care of neonate population
-Educate family/caregivers in patient’s care while inpatient and as they transition home.
-Collaborate with NICU staff nurses to ensure a team effort in care/management of patients
-Collaborate with allied health team, medical students, residents and attending physicians on a professional level
-Provide care of high-risk Obstetrical patients in the clinic to includes Non-Stress Test, Level 2 Ultrasound support
-Coordinate with Nursing and Ultrasound staff of care of high-risk OB patients in the clinic setting
-Provided education to high-risk OB patient on safety, nutrition, self-care, exercise, medical conditions as defined by Maternal Fetal Medicine provider
August 2002- Feb 2003 Astra Zeneca; Pharmaceutical Sales/Hospital Sales Specialist
-Provide education of Cardiovascular and GI pharmaceutical products to hospital physicians in formal and informal settings.
-Planning and implementation of instructional programs on disease process and product use for physicians, nurses, and allied health care staff.
-Planning and implementation of promotional projects, speaker programs, lecture series and seminars at multiple hospital sites within territory.
-Training and education quarterly for up to date clinical and sales data.
-Provide weekly and monthly data and budget reports for regional and national use.
-Quarterly and Annual district and national meetings on team and personnel goals.
-Provide weekly and monthly data and budget reports for regional and national use.
May 2000- June 2002 Pharmacia; Pharmaceutical Sales Specialist Women’s Health
-Launched and introduced three new women’s healthcare products to the healthcare market in June 2000
-Education of physician and nursing staff in OBGYN clinics of pharmaceuticals Planning and implementation of speaker programs, lecture series, seminars for physicians, nurses, and allied healthcare providers.
-Training and education quarterly to meet clinical and sales requirements.
-Quarterly and Annual district and national meetings on team and personnel goals.
June 1996-April 2000 Augusta Surgical Center; Ambulatory Care Surgical Nurse
-Perform duties consistent with ambulatory surgical nurse functions in Operating and Recovery rooms.
-Circulate in surgical cases in a multidisciplinary clinical setting
-Monitoring of multiple complex post op surgical cases
-Monitored, documented and alerted medical staff of status changes in plan of care as indicated
-Staff development and education of nursing staff monthly
-Comprehensive clinical orientation and oversight of new employees
-Provided supportive pre- and post-operative education of patient and family
-Collaborate openly and effectively with the interdisciplinary with clinical staff and vendors
-Coordinated clinical appointments to meet timely expectations of surgical procedures as directed by medical team
-Audited charts monthly to meet federal guidelines
-Peer review monthly of approximately 5 RN’s and 3 LPN’s
-Monitored and audited weekly for lost charges
-Provided telephonic follow up evaluations and recommendations as indicated.
-Clinical skills included IV starts, insertion of foley catheters/ng tube, supportive equipment, positioning, suctioning, dressing as appropriate.
-Provided close monitoring and support for pre-operative, and post-operative sedation
June 1996-April 2000 Augusta Surgical Center; Ambulatory Care Surgical Nurse
-Perform duties consistent with ambulatory surgical nurse functions in Operating rooms and Recovery rooms.
-Circulate in surgical cases in a multidisciplinary clinical setting
-Monitoring of multiple complex post op surgical cases
-Monitored, documented and alerted medical staff of status changes in plan of care as indicated
-Staff development and education of nursing staff monthly
-Comprehensive clinical orientation and oversight of new employees
-Provided supportive pre- and post-operative education of patient and family
-Collaborate openly and effectively with the interdisciplinary with clinical staff and vendors
Augusta 1991-June 1996 University Hospital; Labor and Delivery
Education
Medical College of Georgia-Bachelor of Science in Nursing graduated in
1991
Thomas Jefferson High School graduated in 1978
Licensure
Registered Nurse State of Georgia RN101477 (exp date 1/31/2023)
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