Appeals and UM, remote RN clinical team leader, case management
Resume:
NOVA WOODS BSN, RN, CMCN
P
E
***********@***.***
A
Fountain City, IN
PROFESSIONAL SUMMARY
Dedicated, highly motivated healthcare professional who can leverage a wealth of experience in diverse settings. Proven performance in management, leadership, and communication. Detail-oriented in problem-solving and planning. Ready to make an immediate contribution to your organization.
KEY SKILLS
PROBLEM-SOLVING
TEAM BUILDING
MANAGED CARE
CLINICAL OPERATIONS
UTILIZATION MANAGEMENT
CASE MANAGEMENT
EXPERIENCE
October 2022-Present
RN Clinical Appeals Team Lead
CareSource, Dayton OH
Responsible for managing the day-to-day operations of the clinical appeals nurse team and ensuring contractual compliance with multi-line of business clinical appeals, state fair hearings, and external reviews.
Responsible for internal quality audits of direct reports including thoroughness of documentation and appropriate review criteria application and internal reporting. Responsible for reporting, audit preparation, and presentation for regulatory body audits such as CMS, state Medicaid agencies, and NCQA.
Responsible for clinical policy and procedure writing and review based on contractual requirements, as a proxy author in conjunction with the Enterprise Medical Director and VP of Clinical Appeals and Policy, as well as writing and review of departmental standard operating procedures.
Works closely as a partner with other departments such as UM, operations, program integrity, and regulatory for process review and improvement. Works with organization program managers for new business line implementation.
November 2015-October 2022
Clinical Appeals Nurse
CareSource, Dayton OH
Prioritized and applied appropriate criteria in UM review of member- and provider-submitted clinical and claim-related appeals and external reviews for DSNP, Dual-eligible demonstration plans, multiple state Medicaid, and Marketplace plans, with excellent compliance record and minimal audit errors.
Prepared, collaborated with other involved departments, and participated in State Fair and ALJ hearings.
Assisted with external audit preparation and presentation for Medicaid with positive results.
Served as SME an preceptor for multiple new hires, and served as interim supervisor in absence of team lead.
Worked in process improvement projects in collaboration with other departments, as assigned.
June 2014-Novemember 2015
Associate Case Manager (Temp to Full-time)
Caresource, Dayton OH
Performed telephonic screening, engagement, and intake of high-risk Medicaid members into appropriate case management programs in a call-center setting.
Performed and documented detailed and full telephonic member nursing assessments with minimal audit errors.
Precepted new nursing staff.
April 2007-June 2014
RN Case Manager-Quality Improvement
McCullough Hyde Memorial Hospital, Oxford OH
Performed hospital level of care UM review with nationally recognized criteria such as Interqual and communicated with insurance providers for precertification and concurrent review. Performed QIO appeal submissions.
Interviewed patients and their support persons, provided education on disease, discharge planning, advance directives, and other topics, as needed. Worked in collaboration with physicians and other members of the care team for appropriate discharge planning to the appropriate next level of care. Worked closely with community service providers and AAAs for discharge needs and assessments. Fast-paced, high-volume, and diverse case load through the continuum of care.
Precepted new staff and mentored social work and nursing students from a local university.
Performed chart audits and reported quality measures as appropriate, in conjunction with the QA director. Reviewed for and submitted appeals for RAC and insurer denials.
February 2005-August 2009
Home Health RN Case Manager
Omni Home Care, Richmond IN
Performed direct nursing care and assessment of home patients.
Made referrals and assisted with communication as the patient’s home case manager for additional needed services and resources
Served as preceptor for new hires.
Performed marketing duties including physician office visits and community events.
June 2004-April 2007
RN Medical-Surgical-Pediatrics
McCullough Hyde Memorial Hospital, Oxford OH
Provided direct hospital nursing care to medically- and age-diverse patient populations.
Served as charge nurse including staffing and unit management in absence of the unit director.
Served as preceptor to new staff, performed chart audits, and performed educational presentations, as assigned.
LICENSURE AND CERTIFICATION
Indiana Registered Nurse Multi-State Compact Licensure
Certified Managed Care Nurse (CMNC)
MCG Utilization Management Certification
REFERENCES
Available upon request.
Contact this candidate