KIMBERLY TORTORA RN ACM

**** ******* **, *** ***, CHESAPEAKE, VA 23320

adwp00@r.postjobfree.com PH. 757-***-****

GOAL: FT position as a remote Appeals/UR RN

EXPERIENCE

HUMANA-Mid-Atlantic Senior products FER 2020-2023

Applied clinical knowledge to work with DMAS regulations for Medicare Advantage policies and care coordination. Worked with medical directors in interpreting appropriateness of care and accurate claims payment. Conducted inpatient, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, benefits, and contracts. Consulted with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.

INTEGRATED CARE MANAGER SENTARA HEALTHCARE 2009- 2020

ICM responsible for providing expert clinical leadership to multidisciplinary care team members in the coordination of clinical care, capacity management support, management of patient outcomes and managing financial responsibilities. Ensured medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions and appropriateness of treatment setting by utilizing M C G as well as the recommendations of Optum Physician Advisors.

CRITICAL CARE /CCU RN SENTARA HEALTHCARE 1992-2005

VASCULAR TRAVEL RN 1992

ICU/ PACU / CRITICAL CARE FLOAT RN THE CHARLOTTE HUNGERFORD HOSPITAL, TORRINGTON CT 1986-1992

EDUCATION

RN TO BSN CHAMBERLAIN COLLEGE OF NURSING, DOWNERS GROVE, IL-currently enrolled

DIPLOMA/AD RN 1986 ST. FRANCIS HOSPITAL SCHOOL OF NURSING, HARTFORD, CT

SKILLS

McKesson InterQual 2009 to 2015

Milliman /MCG 2015 to present

Certification : NBCM ACCREDITED CASE MANAGER 2012 - 2024

ACM Number 45016

Clinical Denials Experience

Solid understanding of managed care trends, payer regulations, reimbursement, and the effect on utilization and outcomes of the different methods of reimbursement as well as familiarity with medical records assembly & clinical terminology and inpatient coding terminology.

Contact this candidate