Authorization Nurse Case Manager

PROFESSIONAL SUMMARY

Nursing and Community Service with over 20 years experience and specializing with applying nursing

regulations and procedures and experience with doing teaching and training pertaining to nursing guidelines applying for a challenging position as an RN with the potential for career development and the opportunity to play a role in the company’s growth.

Relevant Qualification

Communicated by oral and written ways with civilians, veterans and families dependants to follow up on their medical care and referred patients to Community Care Services such as referral to Specialists, Physical Therapy, Occupational Therapy, Durable Medical Equipment and Home Health Care Services.

Coordinated medical care for Veterans and patients to follow up with their doctors for post op care, and diagnostic tests such as Xray and Women’s Health by decision making as a nurse provider.

Over 30 years of nursing and worker’s compensation experience with a continuous focus on developing and learning Problem Solving to assists and provide resources to Veterans and Families.

Educated patients and clients and veterans with using the best preventive management principles such as practicing good hygiene such as handwashing and recognizing early signs and symptoms of worsening infection and other medical abnormalities.

Reviewed and processed 150 urgent and 200 non-urgent authorization requests through phone and fax for medical necessity and reasoning according to established criteria. Authorized pending or modify as appropriate.

Coordinated and facilitated communication and collaboration among employers, insurance carriers, physicians, treatment teams, and injured worker following Worker Rights and Protections guidelines.

Coordinated the continuum of patient care in accordance with the vision and goals as per Medicare and InterQual guidelines in accordance with State and Federal Regulations.

Provided 250 retrospective reviews as required for inpatient admission to meeting guidelines for appropriate level of care and precise appropriate level of treatment.

Acted as liaison; Provided multi-disciplinary support for physicians, health care representatives and patients.

Coordinated 50 monthly continuing education in services of Personal Protective Equipment (PPE), Standards Precautions, and Safety with Medication Administration to staff.

Conducted 60 patient health training with topics on COVID, Infection Control, Goals of Infection Control and Prevention, Safety Protocols with Patient Care, Signs and Symptoms with Patient Care and Treatment Protocols per VA Regulations on Hospital Worker Safety.

Pre-Service teacher for 300 minority high school students involved in a summer residency apprenticeship program.

Team player, compassionate, excellent written and communication skills and a multi-tasker.

Experienced with EPIC, InterQual, CPRS, Vista, Lotus Notes, Microsoft Office, CERNER, and ALLSCRIPT.

Knowledge in current procedural terminology (CPT), classification of diseases, and clinical modification (CD-9-CM).

Employment History

Recreation Assistant (FLEX) 2022 - 2023 20 hours weekly

Camp Parks Army Base Dublin, CA

Follow Army Regulations with assessment for work hazards and medication check for expiration dates with employees, veterans and families.

Assist with patron usage facility and assuring service is satisfactory and receives and resolves customer complaints, provides information and general instructions on the use of equipment, facilities and machinery.

Assists patrons in use of the facility by checking out equipment, providing safety instruction, demonstrating new equipment, teaching classes.

Plans, conducts, publicizes and arranges support for special events, social activities, tournaments and related functions.

Provide information, set up computers, great customers, and answer phones.

Open and closes facility, set up register and computer for use, sell drinks and food, assists customers, rent or reserve equipment, cleaning the facility.

Develop ideas for events decide what materials will be needed, cost and availability of materials, staffing, where, and how it is to be held.

Volunteer for Soldier’s Angels (PERM) 2020 – Present 15 hours weekly

Sacramento, CA

Responsible for coordinating volunteers to attend various outreach events in the assigned market.

Works with military affiliated programs, schools, faith-based organizations and other community partners to develop new relationships and partnerships.

Develop relationships with potential local businesses and colleges who have volunteer pools.

Develop relationships with potential donors, businesses, and corporations that have an interest in supporting Soldier’s Angels.

Conduct briefings and coordinates a key team of volunteers to conduct briefings for businesses, corporations, non-profit organizations (VFW, American Legion) about Soldier’s Angels mission, support, engagement, and volunteer opportunities.

RN Authorization Nurse (CONTRACT) 2018 – 2019 40 hours weekly

PriMed Hills Physician Medical Group

San Ramon, CA

Conducted employee training on State and Federal guidelines with methods for preventing the spread of pathogens in healthcare setting by using Standard Precautions.

Reviewed and processed 150 urgent and 200 non-urgent authorization requests through phone and fax for medical necessity according to established criteria. Authorized pending or modify as appropriate.

Obtained additional medical information as necessary from requesting provider.

Communicated with providers and members regarding status of authorization requests.

Collaborated with medical directors and other designated physician leaders for making clinical decisions.

Experienced with using EPIC computer database.

RN Home Health Nurse (perm) 2016 – 2018 40 hours weekly

Nuclear Care Partners

60 Fenton St, Livermore, CA 94550

Performed nursing assessments.

Reviewed patient’s medications and prepared medication reconciliations.

Arranged therapy at home including PT, OT, and ST.

Provided patient education regarding patient’s work injury with the Department of Labor.

RN Case Manager (CONTRACT) 2016 – 2018 40 hours weekly (Hybrid)

Mollie Kallen Worker’s Comp, Inc. Occupational Nurse

Boca Raton, FL

Educated patients and clients and veterans with using the best preventive management principles such as practicing good hygiene such as handwashing and recognizing early signs and symptoms of worsening infection and other medical abnormalities.

Provided medical case management services to people injured on the job.

Followed up with injured workers regarding receiving rehabilitation and medical treatment to promote return to function, early return to work, and claims resolution.

Coordinated and facilitated communication and collaboration among employers, insurance carriers, physicians, treatment teams, and injured worker.

Acted as an advocate in the case management process.

RN Case Manager (ON-CALL) 2012 – 2016 40 hours weekly

San Ramon Regional Medical Center

San Ramon, CA

Conducted in-service on OSHA regulations pertaining to patient and client care with preventing infections with inpatient care setting.

Worked with Managed Care with Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS) plans and Medicare and Medi-Cal patients and insurance carriers.

Coordinated the continuum of patient care in accordance with the vision and goals as per Medicare and InterQual guidelines.

Performed admission and concurrent reviews for patients as described in the hospital utilization review plan.

Coordinated case management functions including review and discharge planning with external review agencies and managed care representatives to assure timely, appropriate transitions in level of care.

Provided 250 retrospective reviews as required for inpatient admission to meeting guidelines for appropriate level of care and precise appropriate level of treatment.

Provided appropriate documentation in the patient medical records and case management worksheet in CERNER and ALLSCRIPT.

RN Case Manager (ON-CALL) 2004 – 2014 40 hours weekly

Alta Bates Hospital

Berkeley, CA

Provided RN teaching for patient education on radiation therapy, side effects, nutrition, skin care, and offered resources as needed.

Assisted with research study for new medication and administer amifostine injection to monitor nausea and vomiting with radiation treatment.

Assisted with surgical procedures such as volume study, vaginal cylinder, and total body irradiation.

Administered lupron injection and monitored any side effects.

Developed new orientation binder for radiation oncology department.

RN Supervisor in the CREC Rehab and Long-Term Units (PERM) 2007 – 2009 40 hours weekly

Veterans Health Administration (VHA Martinez)

Martinez, CA

Supervised staff in the delivery of care for the veteran’s patients with various diagnosis and changing conditions in Sub-Acute, Rehab and Long-Term Care.

Advised nursing staff in the planning, provision documentation, and evaluation of patient care outcomes.

Conducted rounds to insure safe and appropriate nursing care.

Coordinated admissions, discharges and intra-/inter-facility transfers of patients.

Facilitated adequate personnel coverage for quality patient care delivery.

Patient Care Coordinator, Utilization Management (PERM) 2002 – 2006 40 hours weekly

Kaiser Permanente, Inc.

Fremont, CA

Conducted utilization review for in-house patients and conducts clinical reviews based on established treatment criteria per OSHA guidelines.

Assisted other health care providers in the discharge planning process and triaging on alternatives unit of care.

Assisted in collecting and assimilating clinical data to enhance the quality of services.

Interviewed patients and caregivers regarding care after hospitalization.

Counseled patients on Medicare and other health plan coverage.

Case Manager (ON-CALL) 2001 – 2002 40 hour weekly (Hybrid)

Kemper’s Worker’s Comp

Plaza De Oro Commerce Center

Rancho Cordova, CA

Worked with multidisciplinary team, including doctors and physical therapists on patient’s progress with therapy and treatment.

Reviewed patient files and prepared reports for worker’s comp claims.

Discussed and reviewed cases with claim examiners, employers and attorneys if applicable for return to work.

Completed reports for each case for progress and return to work status.

Utilization Authorization Nurse (PERM) 1999 – 2002 40 hours weekly

Hill Physicians Medical Group IPA, Managed Care Organization Dept

San Ramon, CA

Responsible for review and processed medical authorization requests.

Acted as liaison; Provided multi-disciplinary support for physicians, health care representatives and patients.

Coordinated 50 monthly continuing education in services to staff.

Case Manager, Worker’s Comp (PERM) 1997 – 1999 40 hours weekly

Gates McDonald

Concord, CA

Evaluated patients’ treatment plans in work-related injury cases.

Discussed treatment plans and medical management with medical professionals.

Conducted 60 patient health training.

Prepared client progress and status reports through Lotus Notes and interviews of healthcare professionals, patients and insurance companies.

RN (PERM) 1993 – 1995 40 hours weekly

St Anthony’s Convalescent Home

Hayward, CA

Administered nursing care practices including administering medications, taking vital signs, doing wound dressings.

Created a resident care plan and assisted with admissions.

Communicated patient progress and addressed patient concerns.

Performed detailed charting of resident progress notes.

Research Assistant, Pediatric Pain Study (2 Summer Internships) 1992 – 1993 40 hours weekly

UCSF

San Francisco, CA

Pre-Service teacher for 300 minority high school students involved in a summer residency apprenticeship program.

Involved in educational projects and provided in-services in research settings for Dr. Bilal Shabass, research professor and Alma Cisco-Smith, Director of Student Academic Services.

Nurse Officer 1983 – 2006 (Full Time Duty)

United States Air Force – Travis Air Force Base, CA

US Air Force Officer- Nurse Officer, Travis Air Force Base, CA 22 Years of Service

Directed health services operations for over 4,000 patients and providers with other military services.

Diagnosed patient's health conditions and assisted with treatment plans.

Performed daily reviews of nurse logs using guidelines and institutional policies.

Determined appropriate levels of care and readiness for discharge.

Educated other healthcare team members on containment initiatives.

Ensured continuity of care through communication in rounds, written documentation and level of care recommendations.

Coordinated and developed comprehensive discharge planning and obtaining authorizations in conjunction with patient and family needs.

Education

1998-2000 Master of Science (MS)- Public Health Administration Services, University of SF, CA

1989-1993 Bachelor of Science (BS)- Nursing, California State University, San Francisco, CA

2004 Certificate in Nursing Project Management, California State University, Hayward, CA

Military Service

USAF Active Duty Allergy and Immunization 1983-1988 McClellan AFB, CA

USAF Reserves Adult Physical Clinic 1988-1994 Travis AFB, CA

USAF Active- Duty Oncology Floor Unit 1994-1995 Travis AFB, CA

US ANG Reserves Medical-Surgical Unit 1996-1998 Moffett ANG, CA

US Army Reserves Nursing In-Processing Unit 1998-2000 Oakland Army Base, CA

USAF Reserves Utilization Management 2000-2006 Travis AFB, CA

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