Medication Delivery Case Manager

Registered Nurse (RN) with extensive and diverse experience supporting a variety of medical settings through utilization management including pre-authorization processes, case management, and care coordination. Adaptable medical professional with a demonstrated history of succeeding in fast-paced or high-volume environments, employing organizational skills and keen understanding of the healthcare industry to drive positive outcomes in support of diverse patient populations. Dedicated team player and preceptor skilled at building strong relationships with staff, providing mentorship to build collaborative teams.

Areas of Expertise

Utilization Management (UM)

Registered Nurse (RN)

Case Management

Relationship Building

Patient Education

Plan of Care

Pre-Authorization Procedures

Quality Control

Regulatory Compliance

Education & Licensure

Associate Degree, Nursing – Washtenaw Community College

Nursing Licensure – States: Michigan, Alaska, & Washington (State)

Professional Experience & Accomplishments

Evolent Healthcare – Austin, TX (Remote Work) 2019 – 2020

Utilization Management Nurse

Managed authorization requests, referrals, and approvals in a territory covering the state of Washington and Alaska while navigating correspondence across different time zones.

Utilized strong attention to detail and listening skills to understand patient needs; coordinated with social workers and local individuals to ensure that claims were taken care of in a timely manner.

oSecured a range of needs through ad hoc requests, including transportation, medication delivery, and access to food.

oUpheld cultural sensitivity while working with patients from different indigenous backgrounds to ensure administration of care.

Assessed medical claims of current patient conditions, operating as a consultant and providing a recommendation to determine whether the insurance claims would be paid based on regulations.

Maintained professional relationships with Providers and personnel for the purpose of education to establish a smooth operational flow of authorizations and referrals.

Verified accuracy of codes and services and applied them accurately with appropriate documentation.

Neuro Restorative – Ann Arbor, MI 2019

Case Manager

Monitored compliance and the effectiveness of medication for patients with closed-head injuries living in semi-independent housing to ensure continuous support.

Completed all documentation within a timely manner with thorough accuracy.

Acted as the main point of contact for family members and physicians, communicating on a regular basis to recommend changes to medication if needed.

Participated in monthly clinical meetings with patients and family members to outline progress.

Concerto (Specialty Medical Michigan) – Southfield, MI 2019

Case Manager (Contract Position)

Communicated with managers to conduct health risk assessments, routinely calling patients to obtain a complete and comprehensive medical care history.

Acted as a point of contact and key resource to answer any general questions pertaining to medication, treatment costs, and ancillary education for family members.

AmeriHealth Caritas Michigan Blue Cross – Southfield, MI 2018 – 2019

Utilization Management Nurse

Aided authorization requests, referrals, approvals and case preparation for medical review, claims review, request, and review of medical records.

Evaluated medical claims of the current patient condition, operating as a clinical subject matter expert to provide recommendation to determine whether the insurance claim will be paid.

Maintained professional relationships with Providers and personnel for the purpose of education to establish a smooth operational flow of authorizations and referrals.

Ensured compliance with all regulatory bodies at the local, state, and federal level, in addition to navigating a variety of health conditions from the most common to rare disease states, including trials.

Authored denial letter in the utilization management process, in addition to Reviewing clinical and providing determination for inpatient admission and stay for both pediatric and adult patients.

Consistently scored a 100% in all concurrent reviews through the InterQual system.

Molina Health Plan – Troy, MI (Remote Work) 2015 – 2017

Utilization Management Nurse

Reviewed clinical patient information to determine if each individual case required hospital admittance or if a procedure could be done as outpatient; maintained insurance provider standards to determine how many days a patient would be admitted for if needed.

Worked closely with Case Management to help determine and obtain patient needs.

Leveraged a thorough background in healthcare as a Registered Nurse to quickly process case information.

Liaised directly with the Hospital Discharge Planner to identify if any kind of testing had been completed, the patient symptoms, and if surgery would be recommended.

Earned productivity scores around ~90 and a Top 3/50 ranking among nurses.

Utilized different software systems to review clinical documentation and provide determination inpatient admission and stay, including reviewing the CRC II.

Completed concurrent reviews on necessary qualifications through InterQual with a consistent 100% score.

Aetna Health Plan – Detroit, MI 2014 – 2015

Pre-Authorization Nurse

Oversaw Pre-Authorization for review of HCPC coding for approval of outpatient care, DME, and office visits, covering all criteria based on local, state, and federal guidelines.

Demonstrated excellent time management and organization skills in a fast-paced and deadline-driven environment to provide approval and/or denials with associated cause.

Advanced Care – Shelby Township, MI 2014

Hi-Tech IV/Wound Care Registered Nurse

Managed, maintained, and filled Medtronic Pumps while performing home IV infusion for approximately eight patients daily; educated patients and administered various types of medication.

Leveraged a wide array of skills in the role including but not limited to Chemotherapy, Antibiotics, Pain Management, and Pleurex Catheters.

Midwest Health Plan – Dearborn, MI 2012 – 2014

Supervisor of Prior Authorization

As a Case Manager carefully reviewed a wide range of requests that were submitted with clinical teams, including specialist visits, DME, and prior authorization for surgery; keeping members abreast of all their appointments, health information, health education, transportation to appointments, and friendly chats over the telephone to provide any assistance they may require.

Reviewed each request on behalf of the insurance company and either approved or denied the pending proposal based on what service needed to be completed or what procedure needed to be performed.

Led medical assistants in managing over 1K cases daily, evaluating each request based on difficulty; additionally, prepared cases for the Administrative Law Judge for appeals, with a 100% success rate.

Provided referrals for MI Child, MI Child CSHCS, CSHCS, Foster Children, TANF, ABAD, ABW, OAB, Health Choice, Midwest Advantage, and Medicaid.

Served as a patient advocate and liaison between patients, families, doctors, and health care providers.

Technical Skills McKesson InterQual Milliman/MCG JIVA

Twenty years of Homecare including Hi-Tech; providing health information to patients, teaching self-care, how to obtain necessary appointments and equipment.

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