Brenda Lee Hicks

Orangevale, CA *****

Cell: 916-***-****

adzkgh@r.postjobfree.com

Professional Summary: Dependable and self-motivated registered nurse with experience totaling 15+ years in case management, utilization review and prior authorization in health plan and managed care settings. Proven reviewer with a high degree of detail orientation with a demonstrated ability to apply analytical and problem-solving skills while working efficiently in a fast-paced environment with changing priorities.

Skills: MCG/Milliman/InterQual Criteria, Epic, ICD-10 and CPT coding, Determine medical necessity and place of service (admit, concurrent, retro), Physician consultation, HIPPA, Medicare, Medi-Cal, HMO, DOFR, QNXT, EncoderPro, Disease Management, Pre-/Post-surgical education, Accurate documentation, Excellent verbal and written communication skills, Empathic, Active listener, Ability to work effectively with a variety of customers including members, providers, office staff, health plans/medical groups, internal department, community resources and peers, Support a positive work environment and foster teamwork, Computer proficiency: Microsoft Office Suite, EMR

Education/License/Certifications: Master of Science in Nursing (M.S.N.), California State University, Sacramento, current active and unrestricted CA Registered Nurse (R.N.) license, current Case Management certification (C.C.M.), current Public Health Nurse (P.H.N.), current Clinical Nurse Specialist (C.N.S.) license, current Prior Authorization Certified Specialist (P.A.C.S.)

Current ongoing education: online course to obtain a Certified Professional Coder (C.P.C.) certificate through American Academy of Professional Coders. Online course through Stanford Genetics and Genomics Program, second class: Advanced Topics in Genetics and Genomics; working towards certificate of achievement.

Professional Experience:

PriMed Consulting, Inc (Hill Physicians Medical Group):

Prior Authorization Review Nurse, 07/01/2022-Current

●Obtained certification as a Prior Authorization Specialist (P.A.C.S.)

●Review and determine urgent/routine/retrospective authorization requests for medical necessity and place of service according to established criteria

●Collaborate with Medical Directors and other designated physician leaders for making clinical decisions for complicated cases, cases requiring Medical Director determination and arranging Peer to Peer Review

●Communicate with providers and members regarding status of authorization requests

●Assist interdepartmental staff members to resolve issues relating to the authorization process

●Coordinate with Case Managers

Transition Care Nurse, Care Coordination, 10/15/2017-07/01/2022

●Reviewed high volume caseload of inpatient utilization to determine appropriateness and medical necessity using MCG criteria

●Participated in Daily Telephonic Physician Rounds

●Assisted with facilitation of the discharge or transfer plans and provided discharge follow up to assure that medical care was appropriate

●Identified barriers to efficient hospital utilization and facilitate resolution

●Served as a liaison between the hospital, health plan, vendors, and providers

●Transferred to Prior Authorization Review Department

Special Needs Program, Welcome Home Nurse, Clinical Case Manager, (Temp 07/01/2014 to Perm) 09/01/2014-10/15/2017

●Assisted in the transition of care process to facilitate smooth transitions from the inpatient to outpatient settings

●Conducted assessments specific to transition of care

●Assessed members’ understanding of discharge instructions/current treatment plan and reviewed with the member

●Assisted with coordination of post discharge care as needed

●Identified members’ appropriate for ongoing complex case management and referred to CM as appropriate

●Transferred to Transition Care Nurse, Care Coordination Department

Blue Shield of California

RN Health Advocate/Case Manager, 07/15/2007-01/15/2014

●Obtained Certification in Case Management

●Blended role of utilization management (UM) and case management (CM)

●Developed and implemented the plan of care

●Ensured DC planning at levels of care appropriate for the members needs and acuity

●Conducted consultations with Physician and Speciality reviewers

LifeMap/Guided Imagery RN, 07/15/2007-10/15/2007

●Conducted telephonic Pre-/Post-surgical patient education

●Transferred to RN/Health Advocate/Case Manager Department

Disease Management Nurse 04/15/2006-07/15/2007

●Obtained National Asthma Educator Certification (since lapsed)

●Conducted telephonic patient disease management education: Asthma, Coronary Artery Disease, and Diabetes

●Transferred to LifeMap/Guided Imagery RN Department

Folsom-Cordova Unified School District. Credentialed School Nurse, 09/15/2000-10/15/2005

●Obtained Credential in School Nursing (currently inactive)

●Supervised health care to four elementary, schools (2000 children) and their respective preschools.

Kaiser Permanente, Walnut Creek, CA, Staff Nurse I Oncology, Stroke, Pulmonary, & Medical/Surgical Floor, 01/15/2000-10/15/2000

●Staff Nurse

Contact this candidate