Case Manager Nurse

DENISE M. BOYD, RN, BSN, BA

Colorado Springs, CO

ads3z7@r.postjobfree.com 317-***-****

REGISTERED NURSE – BEDSIDE TO REGIONAL CASE MANAGEMENT Building Rapport and Getting Results Through Positive, Clear and Effective Communications Extensive nursing experience from bedside hospice, pediatrics (burns/orthopedics) and psychiatric care, to case management and hospice liaison driving positive results for patients, healthcare providers and insurance providers. Clinical knowledge and experience, organizational skills, and respectful communication style applied to quickly develop rapport. Works autonomously, with a team attitude. Over three years working alongside major insurance companies, Medicare and Medicaid. Expertise includes:

Regional Case Management

Phone, F2F, and Cross-organization Communications

Applying clinical judgement, medical necessity criteria and screening tools based on nationally recognized tools

Criteria for Medical Decision-making (Interqual)

Applying clinical judgement, medical necessity criteria and screening tools based on nationally recognized tools

Coverage Determinations, Reconsiderations, Appeals and/or Grievance processes and regulations

5/6 Day—maximizing return on DRG vs. cost of care

Prior Authorizations, Utilization Reviews, Denial Recovery

Computer Skills (Excel, Video conferencing)

Charting Systems (EPIC, Point Click Care, Allscripts Sunrise Clinical Manager)

CAREER HIGHLIGHTS

Each and every opportunity to help hospice patients transition with dignity, and enduring relationships with their families

In collaboration with insurance providers and care facilities, assisted in recovering over $900k in revenue through denial recovery communication. (Communicare).

PROFESSIONAL EXPERIENCE

COMMUNICARE, Indianapolis, IN 2019 – September 2022 Regional Remote Nurse Case Manager

Oversees the clinical reimbursement and case management services for 6 facilities in Indiana and Ohio for managed Medicare, managed Medicaid, and commercial insurance patients. Manages average case load of 80 patients through daily interface with 30+ business personnel, healthcare professionals and insurance representatives.

• Gathers and reviews clinical documentation to send to appropriate insurance company for continued stay review

• Communicates effectively with facilities and insurance companies to plan for safe discharge to next level of care

• Obtains authorizations, retro authorizations, and files appeals . ANTHEM, Indianapolis, IN 2018 – 2019

Nurse Care Manager I, Health Guide

Telephonic nurse case management. Educated the chronic and complex care population including Diabetes, COPD, CAD, Asthma, Cancer

• Advocated, guided, and intervened on behalf of patients, families, and/or caregivers

• Engaged identified patients in appropriate care management programs ST. VINCENT SETON SPECIALTY HOSPITAL/ ST. VINCENT HOSPITAL/ ST. VINCENT ASCENSION AT HOME, Indianapolis, IN Clinical Hospice Liaison 2018

Upon receipt of a referral, assessed patients for eligibility of hospice services. Coordinated discharge to home, AL, SNF, or inpatient hospice. Provided hospice and end of life education and support to patients and families DENISE M. BOYD PAGE 2 OF 2

Case Manager 2018 – 2019

Upon transfer from St. Vincent Seton Specialty Hospital, carried a caseload of up to 30 adult patients in the Medical Unit. Determined insurance coverage, benefits, and authorizations for treatment. Collaborated with physicians, utilization review nurses, and social workers as well as physical, occupation, and speech therapists to develop plans for patient care; coordinated discharge

Case Manager 2016 – 2017

Managed 15 - 20 patients at St. Vincent Seton Specialty Hospital for patients requiring up to six month treatment programs – executed Concurrent Stay Reviews including Clinical Updates for insurance companies. Conducted cyber rounds in collaboration with a multidisciplinary team of health care professionals. Advised patients and families on goals and barriers to successful treatment and recovery.

GREAT LAKES CARING HOSPICE, Plainfield, IN 2016

Patient Care Coordinator

Marketed hospice services by aligning new partnerships with nursing homes, assisted living facilities, independent residential facilities, and private practices across the north side of Indianapolis. Advised health care professionals on available services and patient benefits.

INFINITY HEALTHCARE MANAGEMENT / THE WATERS, Indianapolis, IN 2015 – 2016 Nurse Liaison/Admissions Director

Developed partnerships with a diverse range of Health Care organizations including a portfolio of ten Indianapolis hospitals to build patient referrals for a long-term care facility. Represented Westpark, Alpha Home, and The Waters of Indianapolis to the health care market. Delivered new relationships with nursing homes, assisted living facilities, and home health care agencies INDIANA UNIVERSITY HEALTH METHODIST HOSPITAL, Indianapolis, IN 2014 Registered Nurse Case Manager

On short-term contract through Around the Clock Recruiting (Sayville, NY), provided case management services for urology and pulmonology patients as well as heart and lung transplant cases. Worked with Medicare and Medicaid to ensure patient access to health care benefits. Facilitated discharges and collaborated with long-term care facilities and hospice services. Provided patient and family education on prognoses, expectations, home care, and follow-up services HARBOR LIGHT HOSPICE, Indianapolis, IN 2011 – 2014 Registered Nurse Case Manager

Coordinated patient services, both internal and external, for terminally ill patients and their families, managing a team of social workers, spiritual leaders, nurse staff, and certified nursing assistants. Assigned tasks and monitored performance to ensure adherence to best practices and company policies. Facilitated meetings to work as a cross-functional team of medical professionals – developed effective end-stage treatment plans and discussed updates on patient records and prognoses. Partnered with social workers to assist patients in securing community resources and third-party services RELATED WELLNESS EXPERIENCE

WORLD’S GYM, Lutz, FLA, Personal Trainer

SHAPES TOTAL FITNESS, Brandon, FLA, Personal Trainer BODFIT BOOTCAMPS, Fishers, IN, Boot Camp Owner/Personal Trainer PURDUE STUDENT NURSES ASSOCIATION, West Lafeyette, IN, President INDIANA STUDENT NURSES ASSOCIATION, Indianapolis, IN, Vice President EDUCATION

Bachelor of Science Nursing (BSN), Purdue University, West Lafayette, IN Bachelor of Arts Psychology (BA), Purdue University, West Lafayette, IN LICENSURE

Registered Nurse (RN): 28192114A – Nurse License Compact (NLC), Indiana State Board Licensing

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