NURSE CASE MANAGEMENT UTILIZATION MANAGEMENT

Compassionate and efficient leader with more than 20 years of experience delivering clinical and non-clinical leadership within government organizations. Highly proficient in case research, clinical reviews, resource utilization, patient care programs, research, and cost benefit analysis. Passionate about maximizing healthcare services for patients, families, and communities. EXPERTISE

• Leadership & Development

• Healthcare Regulations

• Nursing Processes

• Caseload Management

• Patient Care Programs

• Patient & Family Advocacy

• Process Improvement

• Performance Evaluations

• Data Analysis & Reporting

• Resource Utilization

• Investigative Research

• Microsoft Office Suite

PROFESSIONAL EXPERIENCE

CLINICAL NURSE REVIEWER/CASE MANAGER/UTILIZATION MANAGEMENT NURSE MAY 2013 – January 2023 U.S. Department of Veteran Affairs, VHA Office of Community Care - Delivery Operations Baltimore, MD

• Promote a holistic, patient-centric atmosphere by providing direct support to the Office of Community Care (OCC), Delivery Operations (DO), and Payment Operations and Management (POM)

• Apply advanced nursing tactics processes to improve care; possess thorough knowledge of InterQual guidelines, utilization management and review processes, clinical documentation requirements, standards of care, and compliance guidelines

• Conduct clinical reviews to interpret and evaluate data directly related to diagnosis, condition, and treatment to assure appropriate medical necessity, care coordination, and timely utilization of OCC-DO services

• Utilize critical thinking skills and sound judgement to ensure positive outcomes, maximize third-party collections, and deliver performance improvement activities; serve as primary point of contact for clinical adjudication of emergency care claims

• Regularize the clinical components in response to individual health care needs along the illness and care continuum in various settings; compile data and clearly communicate care coordination outcome data systematically as requested

• Enhance patient self-determination and serve as a resource for patients and staff in addressing ethical issues; provide excellent internal and external customer service by incorporating integrity, commitment, advocacy, and respect into daily practice

• Identify and assess resource utilization and safety issues in a cost-effective manner while promoting quality patient care; utilize cost benefit analysis for purchased care requests and perform estimation of OCC-DO services when applicable CHARGE NURSE SEP 2011 – MAY 2013

U.S. Department of Veteran Affairs, Veterans Health Administration (VHA) Loma Linda, CA

• Managed, supervised, and aided the nursing staff with administrative support and patient care, including directing admission, discharge, and general flow of patients to promote a highly patient-centric atmosphere

• Collaborated with 11+ nurses and doctors daily to create care plans that were individualized to each patient’s needs; facilitated emergency reports to hospital nursing staff and ancillary staff, including lab, radiology, and respiratory therapy

• Developed and implemented cohesive training courses that helped educate new nurses; delivered performance evaluations and counseling for up to 15 nurses and reported personnel and administrative issues to senior management K A R Y N

H A I L E Y

443-***-****

adx9ft@r.postjobfree.com

Baltimore, MD

K A R Y N H A I L E Y

PROFESSIONAL EXPERIENCE (continued)

LICENSED VOCATIONAL NURSE INSTRUCTOR DEC 2009 – JAN 2012 Four-D College Colton, Ca

• Provided theory and clinical education for a California private postsecondary education institution approved under California Education Code (CEC) Section 94915; contributed substantially to successful department JCAHO accreditation

• Directed the facility’s LPN program, including recruitment, enrollment, budgeting, and instruction; trained 30 new LPNs annually and monitored the clinical attendance and discipline of students while complying with policies and procedures SCREENING NURSE: MENTAL HEALTH TREATMENT CENTER/COMMUNITY CARE OCT 2004 – AUG 2011 Veterans Affairs, Veterans Health Administration (VHA) Los Angeles, CA

• Leveraged strong assessment skills to conduct screening, diagnostic treatment, and rehabilitation and support services to 20-30 veterans daily; assessed patients in active withdraw and provided interventions to manage physical and psychological symptoms

• Provided education to patients on detox and withdraw, medications, addiction, recovery coping skills, and community resources; assessed and documented patient’s priority of care and recommended appropriate disposition for mental healthcare services

• Facilitated monthly meetings for mental health nurses and developed quality care systems and standards; developed and executed nursing care plans and optimized medical protocols and guidelines UTILIZATION REVIEW NURSE OCT 2003 – OCT 2004

Anthem Blue Cross of California Camarillo, CA

• Reviewed medical information submitted by providers to determine necessity for inpatient and ambulatory services; monitored reviews, analyzed data to identify utilization problems, and evaluated program and delivery of service efficiencies

• Served as a clinical and nursing resource for staff conducting concurrent and retrospective claim audits; demonstrated accuracy and thoroughness through document management and identified process improvements EDUCATION

Bachelor of Science: Nursing 2009

University of Phoenix Gardena, CA

Associate of Science: Nursing 1994

Salt Lake College Salt Lake, UT

CERTIFICATIONS & TRAINING

Registered Nurse Active

State of California

Public Health Nurse Active

State of California

Certified Professional in Healthcare Management (CPHM) 2013 McKesson

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