Healthcare Quality & Utilization Specialist, Case Management
Resume:
Bonnie Riley, BSN, RN
Omaha, NE *****
*******@*****.***
Summary
Patient Centered and adaptable Registered Nurse with demonstrated abilities in evaluating patients to maximize utilization of resources appropriately and delay the progression of disease. Accomplished in developing and actualizing strategies and programs to enhance patient care and coordinate interdisciplinary support teams. Seeking a position within Occupational /Public Health Field. Strong background in this arena, 10 years plus with a wide range of experiences, including emergency and disaster training.
Skills
●Chronic Care Management
●Discharge Planning
●Motivational Interviewing
●Wellness Coaching
●Care Coordination
●HIPAA Compliance
●DME Ordering
●Quality Assurance
●MCG- Milliman Care Guidelines
●Public Health
●EMR-Super User
●Quality & Risk Management
●Telephone Triage
●Critical Thinking
●CMS Guidelines
●Utilization Management
●Clinical Review
●Emotional Intelligence
●Patient Education
●Disaster Training
Experience
Nurse Immunizer, Walgreens Pharmacy, Insight Global Staffing, Omaha, NE
September 2024 to November 2024
Support retail pharmacy location to assist in the administration of any vaccines, boosters, including seasonal immunizations.
Performing influenza and Covid screenings as needing for clinic patients
Assisting patients in education regarding immunizations as well as post-care, and answering any additional questions they may have.
Care Review Clinician, Inpatient Review at Molina Health
December 2023 to June 2024
●Conducted thorough reviews of medical records to assess the appropriateness, necessity, and efficiency of healthcare services provided to patients.
●Utilized evidence-based guidelines and clinical criteria to determine the medical necessity of requested treatments, level of care, procedures, and hospital admissions.
●Communicated effectively with case management teams, physicians, and other healthcare professionals to facilitate the authorization process for medical services.
●Identified opportunities for cost containment and quality improvement within the healthcare delivery system.
●Documented all case reviews and communications in accordance with regulatory requirements and organizational policies.
●Contributed to the development and implementation of utilization management protocols, policies, and procedures aimed at enhancing efficiency and patient satisfaction.
Nurse Vaccinator at Kohlls Pharmacy- Omaha, NE
August 2022 to November 2023
●Worked collaboratively with an interdisciplinary team to provide patient centered care as a clinical nurse contracted to educate patients and administer COVID-19, Flu and Pneumonia vaccines.
●Counseled patients on the emergency use authorization for vaccines, ingredients in vaccines, side effects and efficacy of the vaccine.
●Communicated with insurance providers for authorizations, clinical reviews and cost effective utilization.
●Demonstrated sound clinical judgment and knowledge of emergency action to be taken, including epinephrine administration during an anaphylaxis reaction.
Primary Care Nurse Coordinator at Fort Defiance Hospital Board- Fort Defiance, AZ
September 2021 to July 2022
●Provided case management and care coordination to patients of the Navajo Nation Reservation outpatient clinic. Managed over 1,000 patient case load of both chronically and acutely ill patients.
●Conducted COVID testing, telephone triage and follow-up phone calls for COVID contact tracing.
●Performed diagnosis specific assessments and coordinated follow up with providers.
●Used Motivational interviewing technique in recently discharged patients to assess for
understanding of disease processes.
●Identified free community resources and psycho-social support for patients.
●Identified knowledge deficits, provided patient education based on local Health Department and CDC guidelines. Advised on safety, containment and quarantine.
National Travel Registered Nurse at Maxim Staffing- National Travel
January 2021 to Present
●Rapidly self-oriented to various level one trauma centers and patient environments including critical care settings. Quickly adapted hospital systems to provide solid critical thinking and nursing leadership in executing each assignment.
●Acted as a Float nurse to accommodate various units throughout hospital and primary care clinics and wellness biometric screening events.
●Provided exceptional bedside skilled nursing care in a fast-paced critical care setting.
●Effectively managed ventilators, tracheostomies and multiport IV infusions.
●Managed all facets of telemetry, including central catheters, high risk drug administration and
titration, thrombolytic therapy, dysrhythmia interpretation, and management.
●Coordinated care with other health care professionals including physicians, social workers,
dieticians, nursing staff and physical therapists to provide quality care for patients.
●Counseled caregivers and families on patient care options, advanced care planning and transition
of care services and plan for safe discharge.
Pre-admission Nurse at Boys Town National Research Hospital- Omaha, NE
January 2020 to December 2020
●Collaborated with members of the healthcare team to complete the pre-operative physical, including cognitive, spiritual and psychosocial assessment of patients awaiting surgery.
●Made outreach to patients and families to coordinate and schedule surgical procedures, reviewed medical history, current health status, medications and all documentation for SIS and Next Gen.
●Addressed barriers to discharge, medication and treatment adherence. Intervened based on the treatment plan, evaluated outcomes and liaised with medical providers.
●Identified patient and family knowledge deficits and provided hands-on teaching.
●Ensured completion of pre-op testing, pre-op orders, patient education and reviewed all information and consulted with anesthesia/ surgeons on all issues and concerns.
Occupational Health Nurse at Federal Occupational Health- Omaha, NE
June 2010 to May 2019
●Facilitated employee health assessments and physical exams for newly hired employees and those with work related injury and acute illness. Performed first aid, emergency response and walk-in triage for 10-20 employees on a daily basis.
●Provided wellness coaching, education and counseling support for all staff, state and federal agency employees.
●Conducted quality in-service training orientation on quality improvement, patient/employee safety and infection control to clinical and administrative staff.
●Maintained employee health records for annual physical exams, audiometric exams, vision screening, spirometry, EKGs, glaucoma screening, out of the country /need specific immunizations, urine and phlebotomy.
●Investigated and coordinated care for potential employee exposure to communicable disease.
●Completed documentation and provided clinical updates for FMLA (Family Medical Leave Act) and medical necessity paperwork.
●Performed telephone triage, assessed patient injury, and determined the need for treatment interventions.
●Participated in rounds and reporting meetings. Reported quarterly findings for management on infectious disease regarding exposure.
●Facilitated monthly presentation for employee health services, records and data. Presentation included cost-benefit analyses, financial analyses; clinical outcomes; utilization and practice patterns.
Medical Reviewer at Outcomes Health Information Solutions, Inc. Tarpon Springs, FL
January 2010 to December 2011
●Reviewed medical record claims for accuracy, payment integrity, fraud, waste and abuse for contracted companies.
●Made determinations based on care guidelines. Developed recommendations for further corrective action based on medical review finding, utilization of data analysis and review of provider practices.
●Identified areas of concern for overpayment, errors and made recommendations for corrective action.
●Evaluated cases denied by payers for appropriateness of appeal and initiated the appeals process.
●Ensured patients remain at the appropriate level of care by analyzing data from various sources to identify under/over utilization and improve resource consumption.
Director of Quality Management at Select Specialty Hospital, Omaha, NE
January 2008 to December 2010
●Spearheaded specialized projects for all outcomes related to infection control, risk management, quality improvement, survey readiness, staff education, patient satisfaction surveys, employee health and compliance standards.
●Focused organizational efforts on the improvement of clinical quality performance measures. Coordinated with various departments to streamline policies and procedures.
●Implemented “ Team Device Rounds,” developed Exposure Control Plan, Infection Control Plan and counseling program for needle-sticks.
●Performed audits to provide recommendations based on regulatory standards.
●Drove compliance based standards to improve workflows, quality, and improve patient outcomes.
●Developed fast-track service lines to increase productivity & revenue.
●Conducted all staff in-service training, orientation for new hires, patient safety, infection control, employee health education for all clinical and administrative staff.
●Led agency-wide projects in collaboration with the administration to achieve targeted clinical strategic performance goals.
Education Coordinator, Health Services at Blue Cross Blue Shield of Nebraska, Omaha, NE
January 2006 to December 2008.
●Developed systems and departmental orientation for the health services program including the Utilization Managers, Case Managers and Physician Reviewers.
●Created ongoing training and clinical staff education programs for all continuing education and CEUs.
●Evaluated training effectiveness by auditing results to identify knowledge and skill gaps.
●Maintained credentialing and up to date licensing records.
●Ensured compliance and accreditation standards were upheld and assisted with interpretation of guidelines and related policies.
●Participated in special projects to support compliance efforts.
Education and Training
Bachelor of Science: Registered Nursing -Clarkson College of Nursing- Omaha, NE
Licenses
Registered Professional Nurse: Licensed in the State of Nebraska (Compact e- NLC)- Current
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