Review Nurse Case Manager
Resume:
Rancho Cucamonga, CA ***30
Home 424-***-****
Cell 909-***-****
adu1eu@r.postjobfree.com
adu1eu@r.postjobfree.com
Alvita Kisini
Objective
Continue working in the HMO/Managed Care Industry.
Work experience
Working Temporary Assignment through agency
3/2013 to August 2020 temporary assignment doing ambulatory auths, hospital case mgt for UCLA Santa Monica, UCLA Ronald Reagan, St. John’s Hospital, Out of Area/Out of Network Case Mgt, SNF case mgt. Assist in training new hired case mgrs for hospital case mgt and ambulatory auths case mgt, also worked on the CHF Program.
Supervisor: Deborah Ferguson, UM Manager: Richard Kirkland
UCLA Medical Group
5767 W. Century Blvd. Suite 400
Los Angeles, Calif. 90045
Working Temporary Assignment through agency
8/2011 to 11/2012 Temp Assignment doing Ambulatory Auths Case Mgt at Main Office. Re-located to Culver City Office/Santa Monica Bay Physicians to assist with ambulatory Auths, hospital Case Mgt for St. John’s Hosptial, assist with case mgt for UCLA Ronald Reagan, and UCLA Santa Monica and work with transplant cases.
Supervisor: Deborah Davis, RN UM Director
UCLA Medical Group
5767 W. Century Blvd. Suite 400
Los Angeles, Calif. 90045
4/8/11 to 8/1/11 Temp assignment as a SNF Case Mgr onsite and offsite. Also did Out of Network Case Mgt, ambulatory auths, denials, appeals. Worked with Discharge Program.
Supervisor: Tammy Morrow, RN UM Director
Bright Medical Association
6557 Greenleaf Ave.
Whittier CA 90601
Phone: 562-***-****
Working Temporary Assignment through agency
1/11/10 to 1/21/11 hired after being a temp for 13 months as a Case Management, ambulatory authorizations primarily for Hemet I/II assist with Temecula and Sun City IPA’s and several San Diego IPA’s. Monthly Utilization meetings with IPA and prepare monthly statistics and daily ongoing trending. Also prepare and meet with PCP’s office managers and staff to keep up to date with any authorization issues.
Supervisor: Lisa Cabrera RN UM Director
Prime Care Temecula Office
71391 Kalmia Street
Murrieta, California 92562
North American Medical Management/Corporate Office
3281 E.Guasti
7th Floor
Ontario, CA 91761
Working Temporary Assignment through agency
12/1/08 to 1-10-10 Case Management, ambulatory authorizations primarily for Hemet I/II, assist with Temecula and Sun City IPA.
Supervisor: Lisa Cabrera RN UM Director
North American Medical Management/Prime Care Temecula
3281 E.Guasti
7th Floor
Ontario, CA 91761
Working Temporary Assignment through agency
6/4/2008-10/3/2008 Quality Management Specialist, Case Manager. Researched and gave response to complaints and grievances, special compliance projects. Out of Area, and Out of Network utilization review. Utilizing several computer systems specific to UCLA Medical Group IPA. Trained new staff for same position.
Supervisor: Deborah Davis, RN UM Director Feel free to call her: 310-***-****
UCLA Medical Group
5767 W. Century Blvd. Suite 400
Los Angeles, Calif. 90045
Working as an Independent Contractor
3/8/07-4/30/08 Telephonic review, ambulatory authorizations and case management of outliers, for MSO. Worked with several IPA’s through out the state of California and also Washington State, utilizing the Arcadian Organization System. Trained new staff to work IPA’s that they were assigned to.
Supervisor: Sondra Smith, LVN, UM Dir. Feel free to call her: 800-***-****
Arcadian Management
955 Overland Court
San Dimas, Ca. 91773
Working as an Independent Contractor
2/23/07-3/9/07 Hospital case manager doing utilization review, discharge planning and social work.
Supervisor: Mary Therrien, RN, UM Dir.
Alvarado Hospital
6655 Alvarado Ave.
San Diego, Ca.
Working Temporary Assignment through agency
2/5/07-2/23/07 On site case management, discharge planning, social work on Med/Surg, OB, Peds, at San Antonio Community Hospital. Utilized Diamond Computer system, in the office and on company laptop.
Supervisor: Martha Lopez, RN, UM Dir. Feel free to call her: 909-***-**** x17220
North American Medical Management/Prime Care Inland Valley
3281 E.Guasti
7th Floor
Ontario, CA 91761
Working as an Independent Contractor
8/14/06-2/2/07 Telephonic review, ambulatory authorizations, special projects, for MSO worked with 2 IPA’s Family Care Specialist, Glendale Physician’s Alliance, utilizing the Arcadian Organization System. Trained new staff for hire.
Supervisor: Mary Therrien, RN, UM Dir/Lauretta Jones, LVN, UM Dir. Feel free to call her: 800-***-****
Arcadian Management
955 Overland Court
San Dimas, Ca. 91773
Working as an Independent Contractor
2/1/07-6-2011 Home assessments for clients applying for Long Term Care Insurance includes medical history, activities of daily living, and cognitive assessments. Additional cases include assessing clients for claims, and Lift Program.
LifePlans Inc
Deb Rasmussen, Recruitment Specialist
9 Executive Park Drive, 2nd Floor
Merrimac Merrimack, NH 03054
Working Temporary Assignment through agency
5/06-8/06 High Risk Case Management, issues resolutions, divorce letters, maintaining monthly stats, utilization of HMS and Med Metro computer systems. Trained new staff for hire.
Serving several IPA's, Vantage, Mission, Desert Family Practice Assoc. and Alpha Care.
Supervisors:
Vicki Shirk, RN, MHA; Shameka Coles, RN, MBA
Primary Provider Management Co.
3880 Lemon St. Suite 310 Riverside, Ca. 92501
Working as an Independent Contractor
12/05-5/06 Onsite hospital case management, UR, Discharge Planning covering ICU, Telemetry, Med/Surg, Peds, L&D, at Doctor's Hospital.
Supervisor: Antoinette Montesa, RN
Doctor's Hospital of Montclair
5000 S. San Bernardino St.
Montclair, Ca.
Working Temporary Assignment through agency
11/05-12/05 Ambulatory authorizations by computer utilization of HMS and Med Metro systems.
Supervisor: Shameka Coles, RN,MBA
Primary Provider Management Co.
3880 Lemon St. Suite 310
Riverside, Ca. 92501
Working Temporary Assignment through agency
05/19-11/05 Onsite In Hospital CM, UR/DCP, and in office Telephonic Reviews; ICU, Telemetry, Med/Surg, Peds, Labor & Delivery; Utilizing the Diamond Computer System. Hospitals include: On site: Doctor’s Hospital of Montclair. Telephonic: Chino Valley Hospital, San Antonio Community Hospital, Pomona Valley Hospital, OOA hospitals and local skilled nursing facilities.
Supervisor: Sondra Smith, LVN, UM director. Feel free to call her: 909-***-**** x 11225
North American Medical Management/Prime Care Chino
3281 E.Guasti
7th Floor
Ontario, CA 91761
Working Temporary Assignment through agency
05/12-5/18/2005 – Telephonic UR; Out of Area, Out of Network; ran daily reports for various statistics.
Caremore
10000 Lakewood Blvd
Downey, CA 90241
Working Temporary Assignment through agency
04/19-5/11/2005 – On Site In Hospital CM, UR/DCP; utilizing the Diamond Computer System; ICU; Telemetry, Med/Surg; Labor & Delivery, Pediatrics.
North American Medical Management/Prime Care Corona
3281 E.Guasti
7th Floor
Ontario, CA 91761
Working Temporary Assignment through agency
12/04-4/05 In Hospital Case Management; NICU, ICU, CCU, Telemetry, Pediatrics, Med/Surg.
Bright Medical Group
15725 E. Whittier Blvd.
Whittier, CA 90603
Working Temporary Assignment through agency
9/04 – 12/04 – High Risk Case Manager; Special Projects for UM Director.
Physician Associates
199 South Los Robles Avenue
Pasadena, CA 91101
Working Temporary Assignment through agency
12/2003 – 8/04 Interim Director/Lead Case Manager. Piloting brand new Hospitalist program, in hospital Case Management, Utilization Review and Discharge Planning, Social Services: Independent Contractor through Managed Care Resources
South Coast Medical Center
31872 South Coast Highway
Laguna Beach, Calif. 92561
Supervisor: Linda Feldman, RN Director Case Management
4/2002-11/2003 Case Manager/Discharge Planning/Social Work at San Antonio Community Hospital: Independent Contractor through Managed Care Resources 4/02-6/02
San Antonio Community Hospital
999 San Bernardino Road
Upland, Calif. 91786
Sylvia Swager, Supervisor
Hired as Staff Case Manager and assigned to Orthopedic, Neurological, Neuro-Surgical, Podiatrist, and some Gynecological Doctors. Followed all above doctors’ patients, doing Reviews, weekly case management meetings for patients in house over 8 days, discharge planning and coordinating patient’s care with Physical Therapy, nursing, and other case managers. Heavy discharge planning for numerous surgical orthopedic patients. Including transfers, ordering DME, coordinating with family members, for home health, P.T. and all patients discharge needs. Social work involvement for difficult discharge cases.
Working Temporary Assignment through agency
12/2001-4/2002 Case Manager/Social Services/Discharge Planning at Sherman Oaks Hospital; Independent Contractor through Managed Care Resources
Sherman Oaks Hospital
4929 Van Nuys Blvd.
Sherman Oaks, Calif.
Linda Swavely Supervisor
(Temporary assignment)
Temporary assignments in TCU (Transitional Care Unit), with heavy discharge planning, Geropsyche, and assisted on Med/Surg and Burn Unit.
1999-2001 Case Manager/Social Worker/Discharge Planner, Community Hospital of San Bernardino
Community Hospital of San Bernardino
1805 Medical Center Drive
San Bernardino, Calif. 92411
Yvette Whittaker Supervisor
(Initially Temporary assignment)
Initially worked as a Social Worker for med/surg, as an independent contractor. Trained to do Social Work and Case Management in OB/GYN/NICU/NSY, MED/SURG, ICU/CCU, MENTAL HEALTH and PEDS. Hired as a Case Manager assigned to the Pediatric Unit. This unit had a heavy CPS caseload, along with medi-cal, and HMO utilization and discharge planning. Assist with Risk Management and Quality issues. Continued to assist other case managers as needed.
1998-1999 Case Manager/Social Worker/Quality Manager, Hollywood Community Hospital: Van Nuys/Hollywood Campus
Hollywood Community Hospital Campus
6245 De Longpre Avenue, Los Angeles, CA 90028
Van Nuys Hospital-Psyche Facility
14433 Emelita Street, Van Nuys, CA 91401
Kathy O’Keefe Supervisor
Van Nuys/Psychiatric Facility: Quality Manager and Case Manager for hospital; chart audits/reviews, safety reviews, quality review, monthly committee meetings. Monthly meetings presenting any problems, outliers. Weekly case management meetings dealing with all aspects of the patients.
Hollywood/Acute Facility: Case Managed all patients. Specialized in Bariatrics, and Immune Suppressed Units. Utilization, discharge planning, social services and quality review. Weekly Case Mgt and Quality Mgt Meetings.
1997-1998 Independent Contractor, Managed Care Resources
1516 Westwood Blvd. Suite 201
Los Angeles, Calif. 90024
On site review, case management, discharge planning: Queen of the Valley Hospital, Brotman Medical Center, Hollywood Community Hospital, Daniel Freeman Memorial
Out-patient Review Nurse for: Tenet/CMS Noble Mid Orange County IPA; Garden Grove, Calif. Review ambulatory referrals/high volume, data entry, benefits verification on EZ-Cap Computer System.
On Site Review Nurse for: Lakeside IPA facilities included: Encino Hospital, Encino-Tarzana Regional Hospital, St. Joseph's Hospital/Burbank, Valley Presbyterian Hospital
Quality Review Nurse for Kaiser Permanente Woodland Hills
Worked on a high volume of Cancer Cases to determine if the patients' care was with in the standards of care.
1997-1997 UM/QM Case Manager/Medical Administrator
Physicians' HealthWays-IPA
17595 Almahurst Road, Suite 210
City of Industry, Calif. 91748
Dr. Yu Supervisor
Office Medical Administrator for all aspects of UM, QM, Peer Review, Health Education, Risk Management. Supervisor for staff in these depts. Did Case Mgt, Utilization Review. Revised forms for UM and QM, and also revised policy and procedure manuals. Planned and ran: weekly UM, and monthly QM, Peer Review, and Health Education meetings. Prepared monthly statistical reports for UM trends for contracting HMO. Met at regular intervals with contracting hospital and contracting HMO regarding claims and contracting issues. Negotiated rates and contracts for some providers.
1996-1996 Nursing Auditor for Credentialing Dept.
Independent Contractor for Managed Care Resources
Assigned to Pacific IPA to assist office to catch up on office audits for doctors needing credentialing and re-credentialing. Audited various doctors’ office for the IPA for re-credentialing.
1995-1996 Case Manager
Huntington Provider Group/Uni-Health
141 S. Lake Ave.
Pasadena, Calif. 91101
Judy Beeton Supervisor
Case Manager for non-contracted hospital, out of area hospitals, tertiary hospitals, and in-patient psyche patients. Reviewed patients out of network and facilitated all aspects of their care to get them back in network or discharged, with quality care. Facilitated non-contracted doctors and contracted doctors to provide the best care for patients. Made arrangements to get patients back in network when medically stable, this included patients out of the country. Included but not limited to air, ground and medical team transports while reporting to receiving facility and all staff involved.
Negotiated cost for non-contracted transporting providers. Coordinated with patients' insurance carrier all aspects of their admission, transfer and discharge planning. High volume phone calls, computer, and eligibility benefits check and daily conferences with in house medical director. Weekly reports faxed to insurance carriers, telephonic reviews, and monthly reports for case mgt meetings regarding out of area cases and difficult cases. Coordinated with other case managers, whose patients needed to have extensive care at tertiary hospitals. Case managed these patients while in house, and attempted to keep them in network. Facilitated their discharges and coordinated and reported to their outpatient case managers. Did various statistics including but not limited to LOS, out of area, and out of network. Keep logs for specialized cases, HIV, preemies, transplants. Did ICD-9 and CPT coding. Also responsible for out of network and in network Psyche patients. Including review, transferring in network and discharge planning.
1994-1995 Utilization Manager
Independent Contractor Managed Care Resources
MedGroup Management/Uni-Health
5016 N. Parkway Calabasas
Calabasas, Calif. 91302
Verna Rowe supervisor
(Promoted to Huntington Provider Group)
Initially worked as an independent contractor providing summer relief for nurses on vacation. Hired on after one month, and later promoted and transferred to Huntington Provider Group.
Telephonic review, discharge planning and case managed patients at Santa Monica and Hoag Memorial Hospital. Daily telephonic reviews with medical director on difficult cases. Did Stat and Urgent ambulatory authorizations, and kept daily statistics on volume of ambulatory authorization by IPA's. Prepared reports for weekly meetings on problematic cases for meetings at above hospitals.
1990-1994 Utilization Manager for Pilot Opt-Out Program for Pacific Telesis
Cigna Health Plan
505 N. Brand Blvd.
Glendale, Blvd. 91203
Piloted, set-up, and ran Cigna's first opt-out plan for Pacific Telesis clients for all of Southern Calif.
Prior authorization, second surgical opinions, benefits, receiving phone calls through special nationwide 800-phone number. Heavy computer and phone work. Coordinated care through various providers and other Cigna auxiliary. Successful running of this program lead to Cigna contracting 100's of other Opt-out plans. Trained other staff to this program, which became Cigna's flex-care accounts. Later case managed high dollar cases, including but not limited to: cancer, transplants, HIV, preemies.
1988-1991 Home Care and Private Duty Nursing; worked for; Kimberly Quality Care, Nursefinders, VNA, and self-employed.
Shift nursing and respite care for specialized patients. ALS, Terminal/Hospice, mentally challenged, ventilator/tracheotomy. As a self-employed staff did private duty on an ALS case, coordinated all care including staffing case and assisting family with decisions regarding patients’ desires to turn ventilator off.
1989-1989 Paramedical Examiner; Meditest
10542 Los Vaqueros Circle
Los Alamitos, Calif. 90720
Took history and physicals, and drew labs for processing clients for insurance companies. Included travel to patient’s homes or place of work. Prepared lab specimens by centrifuging and shipping to contracted labs. Also ran telephonic EKG's on patients.
1982-1989 Float Nurse/Staff Nurse
Queen of the Valley Hospital
1115 S. Sunset Ave.
West Covina, Calif. 91790
Floated to specialized areas including, ICU, CCU, COA, DOU, NICU, ER. Piloted and ran Courtesy Exam Room, which later became the after hours Doctors' Office. Helped Pilot and run Trauma Unit, became main triage nurse. Became staff nurse for another Piloted Unit, Neuro-Rehab.
Education
2010 CPR AED renewal
2010 Emergency Nursing Secrets
2009 Colostridium Difficile
2008 Understanding Managed Care II
2006 Nursing Assessment
2002 Laboratory Test Interpretation
2002 - 2003 RN Program Through Excelsior
1999 - 2000 BSN Program Through New York Regents
2000 Meconium Stained Amniotic Fluid
1999 Suspected Abuse: Dependent Adult/Elder; Children
1998 Asthma in Children/ home study
1997 Utilization Review with an Introduction to Case Managed Care Systems, Workmen’s Comp/Managed Care Resources
1997 CPUR (Certified Professional in Utilization Review)/InterQual
1996 Case Management Class home study
1994 Depression/ home study
1993 Nutrition and Herbs/ home study
1991 Managing the Patient at Home/home study
1989 Phlebotomy and IV Certificate/Chaffey College
1982 RN, BSN studies/Azusa Pacific University
1981-1982 LVN Studies/Citrus College
1970-1973 Pre-Med/Biology/U.C. Irvine
Volunteer experience
1986-1989 CPR Instructor; American Red Cross
1986-1989 Co-Founder, Co-Administrator, Pastor's Wife and Counselor for; African Community Church
1977-1981 Missionary in Kenya, East Africa with;
World Vision International, with special training in Indonesia, and Thailand
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