Director Care Review Nurse
Resume:
Susan Heffington RN, BSN, MBA
**** *** ******* *** *** Vegas, Nevada 89102 Phone: 501-***-****
Email: advl1d@r.postjobfree.com
advl1d@r.postjobfree.com
Objective: Seeking a registered nurse position utilizing my RN degree and experience.
Profile:
37 years RN Experience
27 years home health experience
23 years management experience including revenue cycles, appeals and billing
23 years utilization review/case management experience
10 years nursing home LTC experience
5 years hospital/rehab/LTAC experience
1 year Clinic management experience
Education:
Graduated Dec 2017 with MBA with medical focus from UALR
Graduated December 2011 GPA 3.8 BSN from UALR (University of Arkansas at Little Rock)
Certified Chronic Disease Management Nurse September 2010
2023 CPR/BLS
2005-2007 ACLS
Certified Aide trainer through Arkansas Train the Trainer Program DHS OLTC 1988
Baptist Memorial Hospital School of Nursing Memphis, TN Diploma RN 1985
Work History:
September 2017 to present Sunrise Hospital and Medical Center
Using InterQual, Meditech and Navi Health case manage a case load of 20 – 60 patients on a busy med surg unit. Filling in on other units as needed. Evaluate medical necessity for all payer sources on observation level of care making recommendations on LOC changes. Evaluate all Medicare patients for appropriate level of care. Discharge planning for all patient making referrals and communicating with patients, families, nursing staff, medical staff, payers, co-workers and providers to discharge patients to the appropriate level of care.
Feb 2017 to September 2017 Med Partners/MEELEO Travel Nurse Case management: case manage and discharge planning and UR for 20-40 patients in acute care setting.
Jefferson University Hospital Philadelphia PA
Valley View Hospital Fort Mohave AZ
Northwest Medical Center Tucson AZ
Experience with InterQual, McKesson, EPIC, Medhost, Cerner.
Evaluate patients based on needs to determine appropriate level of care and discharge needs.
August 2016- Feb 2017 Director of CM/UR North Metro Medical Center
Directed the department assuring policies and processes were developed and followed to ensure customer service, growth and development and personnel management.
Complete admission reviews using InterQual criteria. Used Meditech electronic medical record program.
Generate timely and accurate reports, attend and contribute to revenue cycle meetings. Assisted with denial and appeals
Developed, implemented, and evaluated the Case Management program to ensure quality patient care consistent with the Hospital mission.
Maintained records of assessments, financials and budgets of the Case Management Department ensuring accurate and completeness.
Promoted a collaborative, interdisciplinary approach towards patients, families and all members of the Case Management team.
Educated medical staff on In patient and observation criteria.
Maintain regulatory knowledge related to Medicare, Medicaid and 3rd party payers.
Follow hospital policies and procedures.
September 2015- August 2016 Nurse Manager Office of Medicaid Inspector General
•Supervise Audit staff, Nurses and auditors.
•Interview and Hire audit staff.
•Interpret complicated technical Medicaid and auditing processes and procedures.
•Testify in hearings and appeals. communicate by mail, email, verbal and by phone with providers, beneficiaries, state agencies related to Audit findings and observations.
•Direct and manage the Nurse Supervisors, Nurse Audit Staff and QA staff to prevent, detect, and investigate fraud, waste, and abuse within the Arkansas State medical assistance program.
•Act as a liaison to staff, Medicaid providers, and recipients by resolving problems and clarifying audit, medical and health care issues.
•Educate Medicaid providers on Medicaid policy, audit findings and Corrective Action Plans (CAPs).
•Assist in adjudication of medically complicated claims, providing direction and interpretation of policy.
•Recommend and promote changes to the state medical programs update, including the provider manual, to promote quality programs and control spending of the state medical programs/services.
•Review new state medical program policy suggestions/recommendations; provides comment from clinical audit perspective.
•Provide assistance in drafting provider manuals, bulletins, and revisions.
•Assist the Arkansas Medicaid Inspector General in the identification and pursuit of agency initiatives. Including physician clinic, LTC, HH and Hospice, mental health providers.
•Use computer software applications such as Cerner to create, manipulate, and edit presentations, reports and documents for presentation to OMIG staff, providers, other state and legislative government agencies.
•Navigate the Internet to find information, including the ability to open and configure browsers; use searches, hypertext references, and transfer protocols; and send and retrieve electronic mail (e-mail).
•Use office equipment to copy, scan, and print and file reports and or claim forms according to current file system.
•Use computer spreadsheet applications to enter, manipulate, and format text and numerical data; insert, delete, and manipulate cells, rows, and columns; and create and save worksheets, charts, and graphs.
•Use computer word processing applications to type text, insert pictures, format, and edit, print, save, and retrieve word processing documents to prepare reports.
July 2013- September 2015 Home Health Section Chief/Director State of Arkansas Department of Health In-Home Services (closed due to State selling to Kindred)
•Direct central office Home Health team of QI/QR/Utilization Management and authorizations.
•Manage Home Health surveys
•Direct Home Health program 74 provider numbers across Arkansas, including licensing for each office.
•Hire staff, provide orientation. Directly supervise the management team of 6.
•Keep up with state and federal regulations related to Home Health
•Serve on leadership team
•Developed processes and communicated information to 74 sites using email adobe connect teleconference and site visits.
June 2012- July 2013 Branch Director Care IV Home Health Little Rock
•Manage Private duty team
•Manage Home Health team-Medicare, Medicaid, personal care, elder choices.
•Preparing office for Medicare certification
•Hire and train new staff
St. Vincent Health Care System 2009-2013
February 2012-January 2013 Clinical Coordinator/Part time VNA
•Manage Private Duty Program
•Manage Rehab Team
•Coordinate scheduling visits for Medicare Medicaid and private duty.
•Coding for billing
•Home Visits and call as required
November 2010-February 2012 St. Vincent Home Care Coordinator
•Manage Private Duty aide program
•Manage Flu Vaccine Program
•Supervise 40 Employees
May 2009-November 2010 Patient Care Coordinator St. Vincent’s Visiting Nurse Association Little Rock, AR
•Clinical coach for a team managing a case load of 140-150 patients including certified wound nurses.
•Responsible for team conferences scheduling and day to day operations for patient care.
•Responsible for education program for entire department.
March 2009-May 2009 worked concurrently PRN at St Vincent Rehab and Baptist LTAC Unit. Offered Full time HH position.
July 2007-March 2009 Patient Care Manger Hospice Home Care Little Rock
•Supervised 2 offices Little Rock and Pine Bluff
•Supervised RN’s, LPN’s and aides.
•Duties included managing team meeting, quality assurance and improvement.
•Served on QAPI, Infection control and education committee.
•Trained new Supervisors
July 2006-July 2007 Wellness Manager for Little Rock Job Corps Health Clinic
•Supervising wellness and health education program.
•Maintaining confidential accurate health records on each student.
•Assisted with training new Wellness Managers at other centers.
•Directed the wellness team of LPN, medical assistant, Drug and alcohol counselor, Dentist, Psychologist and Physicians.
2005-2006 Case Manager Care Network Home Health Little Rock AR
•Managed 80 plus cases for Medicare, Medicaid, and private insurance.
•Responsible for day to day management of patient care record review.
•OASIS management, scheduling and covering visits.
•Team leader for IDC meetings.
2004-2005 Utilization Review Nurse for Arkansas DHS DMS OLTC:
•Interpreted state and federal regulations for surveys of nursing homes for compliance. Surveyed nursing homes using those guidelines.
•Compiled reports using computer software and technical writing skills.
2003-2004 Staff Nurse Mercy Hospital Turner Memorial in Ozark, AR.
• Responsible for total patient care of telemetry patients, recovery room, critical care, medical/surgical, ER and Pediatric patients.
•Medication passes, charting, assessment, rounds with doctors, and procedures.
1989-2004 Area Agency on Aging of Western AR. Inc. Fort Smith, AR.
·Vice President of Nursing 2002-2003
·Program Coordinator 2000-2002
·Human Resource Coordinator 1998-2000
·Supervisor 1992-1998
·Staff Nurse 1989-1992
•Supervised 11 nursing offices and Medicaid transportation department.
•Assisted with agency budget, attended board meetings, reported on staff development safety and employment issues. Wrote grants.
•Developed and implemented policies and procedures.
•Responsibilities included Safety and Health program, Workers Compensation, Unemployment, Personnel Laws, Infection control and OSHA.
Honors
Spring 2010 Dean’s List University of Arkansas at Little Rock
Fall 2010 Dean’s List, Chancellor’s List Math and Science UALR
Fall 2011 Dean’s List, Chancellor’s List Math and Science UALR
References :
Theresa Logan RN CCM
advl1d@r.postjobfree.com
Preceptor at Jefferson Health
Joan Chernowski RN BSN CCM
Case Management Manager
Jefferson Health
advl1d@r.postjobfree.com
Thomas Decker RN BSN
advl1d@r.postjobfree.com
Home Health and Hospice Director former regional nursing director Arkansas Department of Health
Connie Diggs RN BSN CCM
advl1d@r.postjobfree.com
Casemanagement Director
Marilyn Evans RN BSN
advl1d@r.postjobfree.com
Former Director of Home Health Arkansas Department of Health
Elizabeth Smith Inspector General Office of Arkansas Medicaid Inspector General
advl1d@r.postjobfree.com
Contact this candidate