Imperial Valley Documentation Specialist

RAINEE CORIN SAWTELL

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REGISTERED NURSE / CASEMANAGER/ Clinical Documentation specialist Top-performing Baccalaureate Registered Nurse with 18 years experience; 12 years Case Management, Utilization Review, Clinical Documentation, Transition of Care and Discharge Planning. Strong organizational,verbal/written communication leadership skills. Experienced with training & leadership of oncoming staff. Knowledgeable regarding medical necessity, level of care, facilitating care, identifying variations that result in denial & avoidable readmissions.Practiced in review of Clinical for clarification, and validation of Diagnosis. Appeals Process of Denials both DRG, and Utilization of Inpatient stay. Participated in Bioethics committees. Created & managed process improvement plans. Solid assessment ability & over 24 yrs experience in patient care. Experienced in a variety of health care areas Skilled Nursing Facility, Acute Care; Medical Surgical, Intensive Care,Labor and Delivery Postpartum, OB/GYN,perinatal, pediatric,nursery,Emergency Department / Trauma, hospice and home health. Spoken, written Languages Spanish and English

Critical Care Nursing Certified in CaseManagement Research BSN High Risk Perinatal Care IV infusion therapy BLS trained CPR

MIDAS Interqual Cost Reduction Operations Management Mechanical Ventilation Scheduling Regulatory Compliance Wound Vac Placement & Treatment Wound Management Insurance Authorization LOC Grief counseling & Social Services Aetna Health Insurance DSNP Fresno Ca 2020 to 2022 Under a Health Care Managed Organization, Health Plan, Providing Care Coordination, Transition of Care, Motivational Interviewing, Motivational Teaching. For Highly disadvantaged population connecting resources both within the community to bridge and fill gaps in care. Population Health and Social Determinants of health evaluations assessments as risk factors to determine higher levels of needs an acuity

Eisenhower Medical Center, Rancho Mirage, CA 2019 - 2020 Review of Inpatient medical clinical analysis for clarification on variety of diagnosis. Written clarification of possible diagnosis using the most up to date resources. Communication with physicians regarding findings. Management of Diagnostic Related Denials to provide validation of diagnosis. Member of successful Interdisciplinary Team of Coders, Health Information Specialist, and Billers to manage appeals process of DRG denials. Assisted with creations of DRG denial process utilizing interdisciplinary approach. Pioneers Memorial Health Care District, Brawely, CA Clinical Documentation Specialist 2015-2016, 2017 to 2019 Review of Inpatient medical clinical analysis for clarification on variety of diagnosis. Written clarification of possible diagnosis using the most up to date resources. Communication with physicians regarding findings. Management of Diagnostic Related Denials to provide validation of diagnosis. Member of successful Interdisciplinary Team of Coders, Health Information Specialist, and Billers to manage appeals process of DRG denials. Assisted with creations of DRG denial process utilizing interdisciplinary approach. Sharp Health Plan, San Diego, CA 08-2015 to 08-2016 Insurance Case Manager - Care Coordination RN

Under a Health Care Managed Organization, Health Plan that provides both private, medicare and medi-cal health plans; roles included Authorization and prior authorization of medically necessary procedures using milliman care guidelines, specialist, outpatient inpatient care, durable medical equipment. Management of out of Network Care, Care management, transition of care over all levels of care, facilitating transition to in network medically experimental, Transgender surgical medical, psychological treatment under WPATH [World Professional Association for Transgender Health] Authorization for sexual reassignment surgery, Coordination of care with in network. Discovery Coordination and assist with contracting out of network care Hospitals anesthesiologist, and health care providers, after approval of medical necessity, and medical director review. All Authorization and decisions including denials done within a regulated turnaround time. Denial letters written according to DMHC [department of managed health care] regulations. Authorization and review of clinical trials approved by the Food and Drug administration at authorized locations for genotype of cancer and stage of progression using clinical trials.gov. Other tools to review for medical necessity under Health Plan policy included MCG guidelines medline, CMS guidelines, and Up to date . Knowledge of Insurance regulation and coverage for Ill newborns. Review and application of criteria under health plan and policy for persons with riders for fertilization and associated procedures. Review of cases under appeals, transitioned patients from previous health care plan to in applicable networks contracted providers. Telephonic Case management Utilization Case Manager- 2016 -2017

Inpatient Utilization review for authorization of medically necessary acute care, prior authorization through various insurance providers to arrange outpatient follow up. Assisted in transitioning patients out of provider network to in network providers while working closely with insurance to find the correct level of care. Management of denials and 1st and 2nd level appeals.

Case Manager (Pioneers Hospital) 2009-2012

Interdisciplinary Team Meetings, Transition of Care, Utilization Review, Social Work, Discharge Planning, Referral to Outpatient Providers, Assist with acquiring medical insurance. Medicare guidelines & regulations

Access Case Manager RN

Initial screening and review of Criteria to establish medical necessity. Referring to OP resources. Avoidance of readmission. Physician and Staff education.Performance Improvement, Orientation Handbook

Case Manager (Pioneers Hospital) 2009-2012

Interdisciplinary Team Meetings, Transition of Care, Utilization Review, Social Work, Discharge Planning, Referral to Outpatient Providers, Assist with acquiring medical insurance. Medicare guidelines & regulations

Accomplishments:

* Created Implemented Plan to Reduce Re-admissions

* Assist successful flow of Direct Admissions

* Created a Standardized Orientation Booklet for New Trained Case Managers

* Successful in the primary implementation of Access Case Manager

* Successful in Assisting w/ Implementation of IDT meeting coordination Registered Nurse (Pioneers Hospital) 2008-2010

Flexibility in scheduling, adaptable, high energy, dynamic team player. Core Competency in Medical Surgical, Intensive Care Unit, Emergency Department, Postpartum. Accomplishments:

* Successful Implementation as Primary RN Float Pool

* Raised awareness of staff regarding needs and benefits of flexibility

* Educated staff on use of float pool decreased overhead vs travel nurse RAINEE CORIN SAWTELL

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760-***-**** raineesawtell@gmail

Case Manager ( Gentiva Home Health) 2007-2008

Scheduling treatment with Community Health Providers. Identifying and treating patient health care needs.

Case Manager ( Accent Home Health ) 2006-2007

Scheduling treatment with Community Health Providers. Identifying and treating patient health care needs.Insurance authorization, Medi-cal TAR

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Registered Nurse ( El Centro Regional Medical Center ) 2004-2005 Bedside nursing of Postpartum Recovery Pediatric Intensive Care Medical Surgical Patients .

* Development of Educational Material and resources for High Risk Postpartum Depression

* Identifying criteria for high risk postpartum depression

* Patient & family education s/s of PPD & Interventions Registered Charge Nurse (Pioneer Hospital ) 2001-2004 Registered Nurse (El Centro Regional Medical Center) 2001 -6-2001 Registered Nurse (Hospice of Imperial Valley) 2003-2004 COMPUTER SKILLS

Laptop PC Microsoft Word Microsoft Excel Midas Interqual Google Docs Google Calendars Microsoft Calendars Basic Windows Explorer

Chrome Basic Principles of Computer Technology Copying Faxing Xerox Scanning Email Mckesson, Quadramed, Affinity, quickchart, Milliman, Facys, API, CDMP, Nuance EDUCATION

Imperial Valley College Associates Degree Science of Nursing 1998-2001 University of Phoenix Bachelors Degree Science of Nursing2010- 2012 Capella University Partial Masters Degree in Science of Nursing Specialty Education 2022 REGISTRATIONS / CERTIFICATIONS

BLS American Heart Association ACMA affilitation

Certification with Commission for Case Managanager Certification 4238308 JA Thomas test passed for clinical documentation specialist California Board Of Registered Nursing

587170

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