BERNICE

DUNCAN

adug17@r.postjobfree.com

651-***-****

Bloomington, MN 55437

SUMMARY

Collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity, and promote effective use of resources. Medical necessity reviews may include planned elective services, surgical and diagnostic procedures, durable medical equipment, and out-of-network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.

SKILLS

Clinical experience 5yrs and 8yrs as a Case Management Analyst.

Excellent interpersonal and communication skills with nursing staff, physicians, nurse practitioners, and other health workers involved in the care of members.

Experience in Regulated managed care setting.

Strong organizational, planning, and communication.

Knowledge of insurance industry medical coding (CPT/HCPS/ICD-10) and overall claims process.

Knowledge of National Coverage Determination, Local Coverage Determination, and MCG Criteria.

Strong Customer orientation from escalation to de-escalation.

Ability to meet deadlines, manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments.

Possess the ability to work in a dynamic, fast-paced team environment and to promote team concepts

Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel, Presentation, and Word.

EXPERIENCE

CASE MANAGEMENT ANALYST 11/2014 to Current

Cigna Behavioral Health - Eden Prairie, MN

Responsible for the effective and sufficient support of all Utilization Management activities including a review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.

Uses an established set of criteria to evaluate and authorize services' medical necessity.

Provide notification of decisions by compliance guidelines.

Coordinate with Medical Directors when services do not meet criteria or require additional review.

Participation in staff meetings, regular training, and other collaborative meetings as appropriate.

Works with the management team to achieve operational objectives and financial goals.

Supports teams across UM Department.

Active participation and completion of all required training.

Adherence to regulatory and departmental timeframes for review of requests

Meet/exceed department Turn Around time, daily established productivity goals, and service levels

Proficient knowledge of policies and procedures, Medicare, HIPPA, and NCQA standards;

Professional demeanor and the ability to work effectively within a team or independently;

Other duties as required

HEAD PRENATAL NURSE COORDINATOR 11/2010 to 12/2013

Open Cities Health Center - St. Paul, MN

Applied clinical judgment and comprehensive knowledge of facility policies to assist floor nurses with patient care decisions.

Evaluated patient needs and preferences to build and update tailored treatment plans.

Improved patient outcomes through peer groups and facilitated continuing education.

Provided case management, milieu management, and emergency intervention.

Maintained awareness of advances in modern medicine, including computerized diagnostic equipment, data processing technology, sanitation protocol, and life support machinery.

Imparted medical, operational, and patient care knowledge to junior nurses, supporting personal growth and enhancing professional development.

Maintained a comprehensive base of unit supplies to meet expected patient demands, public health emergencies, and mass casualty incidences.

Managed the performance of 15-person nursing staff, reviewing task completion, prioritization, and report quality.

EDUCATION AND TRAINING

Capella University - Minneapolis, MN

Bachelor of Science

Public Health, 06/2021

The National Society of Leadership and Success Member

3.5 GPA

Dean's List Honoree made it 4 semesters 2017-2021

Completed coursework in statistics, epidemiology, and research/ presentations.

Brown Mackie College - Merriville Indiana

Diploma

Practical Nursing, 05/2009

Completed continuing education in Nursing

3.2 GPA

License No. 071043-9

Commonwealth Business College - Merriville Indiana

Associate of Science

09/2004

Major in Business Management

3.2 GPA

Honor Roll all 4 semesters

Completed coursework in Accounting, Presentation, and Communication

Olympia College - Merrillville, IN

Diploma

Medical Administrative Assistance, 06/2006

97.63 GPA

Dean's List Honoree 5 Semester and 2

Completed coursework in ICD-9-CM, ICD-10-CM, and ICD-10-PCS codes, Medical Terminology, and Dental Hygienist

St. Paul College - St. Paul, MN

Certification

Phlebotomy, 05/2010

ADDITIONAL INFORMATION

I am a certified NPA, CMAA. Will be working on finishing my Doctoral Degree in come 2022 Fall Semester.

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