Case Manager Utilization Review
Resume:
MARY CONYERS-TAYLOR
Nurse Case Manager
Mconyerstaylor@gmail
.com
CAREER OBJECTIVE
WORK
EXPERIENCE
Centene, New York, NY
Supervisor Medical Case Management (Telecommuter) July 2020- Present
Responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning. Primary duties may include, but are not limited to: • Ensures member access to services appropriate to their health needs. • Conducts assessments to identify individual needs and a spe fic care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. • Coordinates internal and external resources to meet identified needs. • Monitors and evaluates effectiveness of the care management plan and modifies as necessary. • Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. • Negotiates rates of reimbursement, as applicable. • Assists in problem solving with providers, claims or service issue
Corvel, Duluth, GA
RN Case Manager Occupational Health /Telephone Triage Nurse (Telecommuter)
Jan 2013 – Apr 2020
Managed Accounts: National accounts including multiple airline carriers and Fortune 100 employer Groups,
Responsible for providing telephonic and onsite case management for a variety of insurance carriers.Demonstrated compliance with facility-wide Utilization Management policies and procedure, specific to the responsibilities held by the Case Management Department.Reviewed inpatient admission with the use of InterQual and Milliman Care criteria.Assured department is identifying and negotiating the fullest possible reimbursement to maximize insurance benefit coverage for the patient.Collaborated with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.Manage network participation, care with specialty networks, coordinate with DME providers, and transfers to alternative levels of care using knowledge of benefit plan design.Identify potentially unnecessary services and care delivery settings and recommend alternatives if appropriate by analyzing clinical protocols.Facilitate peer-to-peer process, interaction with payor, and external physician advisors.Travel onsite to hospitals to complete utilization review and discharge planning in collaboration with hospital Utilization review and Case Management departments
Georgia Power/Southern Company, Atlanta, GA
Medical Case Manager SR /Occupational Health
Sep 2010 – Jan 2013
Responsible for providing telephonic and onsite medical and disability case management to employees to implement an expedited return to work for employees out of work related to FMLA, STD, LTD or other medical disability.Worked independently in a home office environment.Travel onsite to hospitals to complete utilization review and discharge planning for catastrophic cases.Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelinesActively participates in identification of opportunities for improvement and assists with action plan development and problem resolution
Bunch and Associates, Lakeland, FL
Medical Nurse Case Manager/Occupational Health
Account: CVS Pharmacy, Lowes, Kmart National Account Management
Jan 2008 – Sep 2010
Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate.Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care.Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. Self-Employed, Atlanta, GA
Independent Nurse Case Manager /Occupational Health
Jun 2006 – Sep 2008
*Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines*Actively participates in identification of opportunities for improvement and assists with action plan development and problem resolution*Acts as a liaison for the health plan with outside entities, including, but not limited to physicians, hospital, health care vendors and facility Case management Department*Reviews selected claims and retrospective requests for certification and follow-up as necessary with HeatlhServices Supervisor, Manager of Inpatient Utilization or Medical Director
Independent Medical Case Manager (Inpatient Hospital)
Jun 2004 – Jan 2005
Documenting clients’ case management plans and on-going activitiesIdentifying clients’ insurance coverage or other sources of payment for servicesIdentifying and addressing client risk factors and/or obstacles to careIdentifying client needs, current services, and available resources, then connecting the client to services and resources to meet established goalsCommunicating the care preferences of clients, serving as their advocate, and verifying that interventions meet the client’s needs and goals of treatment.
Intracorp/Cigna, Norcross, GA
Onsite Medical Case Manager
Jan 2005 – May 2006
Responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning. Primary duties may include, but are not limited to: • Ensures member access to services appropriate to their health needs. • Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. • Coordinates internal and external resources to meet identified needs. • Monitors and evaluates effectiveness of the care management plan and modifies as necessary. • Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. • Negotiates rates of reimbursement, as applicable. • Assists in problem solving with providers, claims or service issues
Sedgwick, INC, Nashville, TN
Supervisor Medical Case management/Occupational Health
Account: Home Depot Corporate
Jan 2004-Jan 2005
*Set team direction, resolved problems and provided guidance to members of the team*Ensures team meets established performance metrics and performance guarantees*Adapts departmental plans and priorities to address business and operational challenges*Responsible for clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)*Manage relationships with physician practices*Manage implementation of new physician practices and deployment of resources*Manage client relationships prior authorization and concurrent review for 20– 45 shared risk facility inpatient admissions, and maintained essential relationships with contracted providers, IPAs and internal departmental staff. *Provided onsite acute inpatient concurrent review for 22-30 charts each day, and served as liaison between plan and hospital for 3 medical centers. *Performed onsite visits reviewing charts per Milliman guidelines and discussed special cases with Medical Director. *Fostered and strengthened working relationships with internal and external clients including medical groups, hospital-based personnel, and wide scope of internal decision-makers. *Provided essential training of nursing staff and mentorship that garnered improved utilization reviews and achievement of 100% chart audit accuracy over 3- to 6-month period. *Reduced bed days by strategic collaboration with team members addressing outliers, and negotiated cost effective case rates with non-contracted providers.* Efficiently processed standard appeals within 30-day TAT.
Genex Inc Glen Burnie, MD
Supervisor Medical Case Management/Occupational Health
Jan 2000 – Jan 2004
Accounts: Delta, American Airlines, Home Depot, and other national accounts
Provided Catastrophic Case Management and emergency injury management
Utilization Review Management
EDUCATION
Notre Dame University of Maryland Baltimore, MD
May 1988
Union Memorial School of Nursing Baltimore, MD
May 1988
ADDITIONAL SKILLS
Catastrophic Case management (10 Years)
Trauma and ICU nursing experience (3 Years )
Volunteer for multiple charitable organizations (10 Years)
Utilization Review (10 years)
LICENSES &
CERTIFICATIONS
Registered Nurse /Certification GA#118060
Certified Nurse Case Manager # 41752
Compact RN Licensure #118060
BLS Certified/ ALS Certified
REFERENCES
References available upon request
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