Manager Assistant Review Nurse
Resume:
From: Kat Morelock ads455@r.postjobfree.com
Subject: Kat Morelock, LVN Case Manager/ Utilization Review Nurse/ Prior Authorization… Date: October 7, 2022 at 8:29 PM
To: kat Morelock ads455@r.postjobfree.com
Kat Morelock, LVN Case Manager/ Utilization Review Nurse/ Prior Authorization Nurse/ Case Manager
Skills Summary:
Managed Care/Medicare/JAHCO/HCFA Regulations/ NCQA Regulations InterQual /Milliman and Roberts/ MCG/ HEIDES Reporting Data Entry Skills
Coding/ CPT-4 Coding/ICD-10 Coding EZ-CAP/EZ-CARE/Microsoft Word/Excel/Powerpoint/Explorer/Access/Outlook/AS- 400/ MIDAS/ Medi-Tec/ QXNT System Work Experience:
Henry Mayo Newhall Hospital: Santa Clarita, Ca: July 2022-present: LVN Discharge Planner
Helped plan an interdisciplinary approach to continuity of care and a process that includes identification, assessment, goal setting, planning, implementation, coordination, and evaluation. ensure continuity of quality care between the hospital and the community. Helping reduce hospital length of stay and unplanned readmission to hospital, as well as to improve the coordination of services following discharge from hospitals.
Regal Medical Group: Northridge, Ca: August 2020-December 2021: LVN Denials Nurse
Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to the denial letters. Process denial letters for the affiliated groups, interpret denial language provided by the prior authorization nurse, coordinators and medical directors and translating medical terminology into lay language and grading the reading level as appropriate for members. Worked closely with the coordinators in the department for clinical guidance on denial cases.
Molina Healthcare: Long Beach, CA: February 2014- August 2020: Care Review Clinician 1
Assessment of the patient's level of functioning prior to admission. Provide insight into resources
available post discharge.
Ongoing collaboration between the patient, family and the interdisciplinary team which facilitates
the process of informed decision making.
Work closely with Case Management team as well as
physicians and nurses to help patients in an
acute setting transition to a lower level of care. Remove barriers to the patient’s timely discharge from a hospital or long-term acute-care environment. Join daily rounds with the medical staff and physicians, meet with patients and families to discuss placement options into nursing homes or assisted- care facilities, organize medical records for transmittal to a rehab facility, provide advice on durable medical equipment and negotiate with insurance companies. Arranged out of state transportation. Evaluate Insurance Eligibility/Review Health Plan
Benefits Coverage.
Identify appropriate providers and facilities
throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source. Obtain prior authorization for DME equipment and SNF placement for HMO clients and transferring
clients to their appropriate capitated Hospital once stable. AhohaCare: Honolulu, HI: September 2013- December 2013 Prior Authorization Nurse
Prior Authorization Nurse
Obtain authorizations for Managed Care patients and utilize specific guidelines and policies.
Collaborate with the RN Supervisor to promote quality and cost-effective outcomes. Identify appropriate providers and facilities
throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source. optimum value for both the client and the reimbursement source. Evaluate Insurance Eligibility/Review Health Plan Benefits Coverage. Ongoing collaboration between the patient, family and the interdisciplinary team which facilitates
the process of informed decision making.
California Hospital Medical Center: Los Angeles, CA : Sept 2006 – July 2010 & March 2011 – March 2013 Case Manager/Utilization Review/Chart Audit and Case Manager Assistant Utilization Review/ Chart Audit – (11/11 – 3/13)
Chart Auditing for Quality Management
Chart Audit Prep and Review
Chart Reviews for Medi-Cal, Medi-Care and HMO’s
Evaluate Insurance Eligibility
Case Manager Assistant- (3/11 – 11/11)
Assessment of the patient's level of functioning prior to admission. Provide insight into resources
available post discharge.
Ongoing collaboration between the patient, family and the interdisciplinary team which facilitates
the process of informed decision making.
Work closely with Case Management team as well as
physicians and nurses to help patients in an
acute setting transition to a lower level of care. Remove barriers to the patient’s timely discharge from a hospital or long-term acute-care environment. Join daily rounds with the medical staff and physicians, meet with patients and families to discuss placement options into nursing homes or assisted- care facilities, organize medical records for transmittal to a rehab facility, provide advice on durable medical equipment and negotiate with insurance companies. Arranged out of state transportation. Case Manager/Utilization Review/ Prior Authorization Nurse – (9/06 – 7/10) Case Management/ Utilization Review responsibilities divided equally with Prior Authorization responsibilities. Identify appropriate providers and facilities
throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source. Obtain prior authorization for DME equipment and SNF placement for HMO clients and transferring
clients to their appropriate capitated Hospital once stable. Evaluate Insurance Eligibility/Review Health Plan
Benefits Coverage.
Assist in patient referral requests utilizing EZ-Cap and EZ-care software.
Obtained pre-authorization from contracted Health
Plans for medical services.
Chart Audit for Quality Management
Valley Presbyterian Hospital / All’s Well Healthcare, Van Nuys, CA: July 2010 – January 2011 Case Manager/Utilization Review
Assist with the planning, coordination, monitoring, and evaluation of medical services for a patient
with emphasis on quality of care, continuity of services, with emphasis on quality of care, continuity of services, and cost-effectiveness. Develop and
implement a plan of care, coordinate medical resources, communicate healthcare needs to the individual. Monitor individual’s progress and promote cost-effective care. Serve as a means for achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation.
Reduce frequency and duration of hospital admissions. Improve clinical and social outcomes and cover
financial accountability in terms of evaluating and monitoring costs and resources. Obtain authorizations for Managed Care patients and Obtain authorizations for Managed Care patients and utilize specific guidelines and policies.
Collaborate with the RN Supervisor to promote quality and cost-effective outcomes. Arrange and initiate referrals to Home Health
agencies, SNF placement and arrange DME equipment. Responsible for providing oversight on low and high
risk cases throughout the continuum of the
patients health care needs through collaboration with the patient and those involved in the patients care.
Initiate the individual’s care plan, and identify
appropriate health care resources based on the patient’s medical needs. Managed Care Resources: Los Angeles, CA: June 2003– November 2005 Case Management/ Utilization Review/ Prior Authorization Nurse Facilitate appropriate medical and rehabilitation
support programs and coordination of care. Serve
as Patient Liaison with various professionals and agencies and arrange for community resources when no appropriate programs were available.
Responsible for internal and external Utilization
Review. Established the medical necessity for appropriate level of care. Specified procedure for denials, appeals and peer review within the organizations and established corrective action and documentation requirement for utilization
process.
Obtained prior authorization for DME equipment and SNF placement for HMO. Evaluate Insurance Eligibility.
Review Health Plan Benefits Coverage.
Assist in patient referral requests and utilize EZ-Cap and EZ-care software.
Obtained pre-authorization from contracted Health
Plans for medical services.
Chart Audit for Quality Management.
Sherman Oaks Hospital, Sherman Oaks, CA: February 2004– October 2004 Case Management/ Utilization Review:
Develop and manage a plan of care for patients
through coordination with community resources. Responsible for discharge planning and case referral if necessary. Served as patient Liaison,
coordinated consultation and encouraged patient and family participation. Reduce frequency and duration of hospital admission Improve clinical and social outcomes and cover financial accountability in terms of evaluating and monitoring costs and resources. Obtain authorizations for Managed Care patients and utilized specific guidelines and policies.
Collaborated with the RN Supervisor to promote quality and cost-effective outcomes. Arrange and initiate referrals to Home Health
agencies, SNF placement and arrange DME equipment. Responsible for providing oversight on low and high
risk cases throughout the continuum of the
patients health care needs through collaboration with the patient and those involved in the patients care.
care.
Initiate the individuals care plan, and identified
appropriate health care resources based on the
patient’s medical needs.
Northridge Hospital, Northridge, CA: March 2001– April 2003 Case Management/ Utilization Review/ Prior Authorization Nurse: Develop and manage a plan of care for patients
through coordination with community resources. Responsible for discharge planning and case referral if necessary. Served as patient Liaison,
coordinated consultation and encouraged patient and family participation. Reduce frequency and duration of hospital admission Improve clinical and social outcomes and cover Reduce frequency and duration of hospital admission Improve clinical and social outcomes and cover financial accountability in terms of evaluating and monitoring costs and resources. Obtain authorizations for Managed Care patients and utilized specific guidelines and policies.
Collaborated with the RN Supervisor to promote quality and cost-effective outcomes. Arrange and initiate referrals to Home Health
agencies, SNF placement and arrange DME equipment. Responsible for providing oversight on low and high
risk cases throughout the continuum of the
patients health care needs through collaboration with the patient and those involved in the patients care. Initiate the individuals care plan, and identified appropriate health care resources based on the patient’s medical needs Education and Certifications:
-Concord Career Institute, North Hollywood, CA - Vocational Nursing Degree
-Current Active California Nursing License
-Basic Life Support/CPR Certification – Current
Contact this candidate