RN Case Manager and Utilization Review Expert
Resume:
Angelete Hayes
*********@*******.***
*** *********** *** ****. *******, Fl 33764
PROFESSIONAL SUMMARY
• Registered Nurse (RN) Case Manager with 14+ years of experience in Case Management, Utilization Review, Care Coordination, Appeals, Medicare/Medicaid, Hospice, Behavioral Health, and Veterans Healthcare.
• Also has the most recent experience with Dragonfly tool in Empath Hospice facility.
• Certified Case Manager (CCM) with expertise in medical necessity review, discharge planning, transitions of care, and utilization management.
• Extensive knowledge of Medicare claims processing, ICD-9, ICD-10, CPT, and HCPCS coding.
• Experienced in inpatient, outpatient, hospice, behavioral health, home health, and managed care settings.
• Skilled in chart review, clinical documentation improvement, appeals management, and regulatory compliance.
• Strong background in case management for complex medical, behavioral health, and veteran populations.
• Proficient with InterQual, Milliman, ASAM, LOCUS, CASII, and other evidence-based clinical guidelines.
• Experienced in coordinating interdisciplinary teams to improve patient outcomes and ensure quality care.
• Knowledge of HIPAA regulations, HEDIS reviews, quality management, and healthcare compliance standards.
• Skilled in transition of care planning, discharge coordination, and patient/family education. SKILLS
• Case Management
• Utilization Review
• Care Coordination
• Discharge Planning & Transition of Care
• Medical Necessity Review
• Medicare & Medicaid Compliance
• ICD-10, ICD-9, CPT & HCPCS Coding
• Behavioral Health & Substance Abuse Review
• Appeals & Denial Management
• Clinical Documentation & Chart Review
• Hospice & Palliative Care
• Veterans’ Healthcare Services
• InterQual & Milliman Guidelines
• HEDIS & Quality Improvement Programs
• Electronic Medical Records (EPIC, CAPRI, JLV,
VBMS, AIDIN)
EXPERIENCE LICENSES AND CERTIFICATIONS
Specialty and Job classifications: Registered
Nurse (RN) Case Manager
Years of Experience: 15+ years
Travel Experience: 2+ Years
Charting type experience: EPIC
FL RN License #21305368 Exp: 04/2027
Certified Case Manager (CCM) Exp: 05/2029
EDUCATION
BSN 11/2017
Kaplan University
ASN 01/2013
RN ITT Technical Institute (RN Program) in Tampa, FL LPN (Licensed Practical Nurse) 11/2008
Galen School of Nursing, St Petersburg, FL
M.Ed. in Educational Leadership/Management 12/2002 University of West Florida, Pensacola, FL
WORK EXPERIENCE
Facility: Simply Healthcare Plans, Miami, FL 06/2026 - Current Job title: RN Utilization Management Review
• Facility Type: Managed Care / Health Insurance Organization
• Position Type: Travel
Responsibilities:
• Evaluate prior authorization, concurrent, or retrospective requests against approved medical necessity criteria. Collaborate with doctors, hospitals, and care teams to support safe discharge planning and appropriate care settings. Ensure all decisions follow state Medicaid/Medicare regulations and contractual guidelines. Act as a liaison between patients, families, and medical providers to explain benefit coverage and secure alternative resources. Employment Gap 03/2026 - 05/2026
Reason: Personal time off
Facility: Empath Hospice, Clearwater, FL 09/2025 – 02/2026 Job title: RN Utilization Review/Case Manager
• Facility Type: Medicare-certified Inpatient & Home-Based Hospice Care.
• Position Type: Travel
• Bed Count: 80
Responsibilities:
• Works under a licensed physician to manage discomfort and provide symptom relief using specialized palliative and end-of-life care skills. Conducts initial and ongoing assessments of patients’ physical, functional, psychosocial, and environmental needs, including activities of daily living. Collaborates with the Interdisciplinary Group (IDG) to develop, implement, and update individualized care plans; initiate preventive/rehabilitative procedures and referrals. Educates patients, families, and caregivers about disease processes, palliative interventions, the dying process, and safety practices. Maintains confidentiality, applies professional boundaries, and supervises LPNs/paraprofessionals. Reviews and updates care plans, physician orders, medication reconciliation, and other records. Adheres to Florida Nurse Practice Act, hospice nursing standards, and regulatory requirements. Provides transitional care to palliative care in nursing homes or home health care. Employment Gap 06/2025 - 08/2025
Reason: Personal time off
Facility: Veterans Benefits Administration, Regional Office, St. Petersburg, FL 03/2023 - 05/2025 Job title: RN Utilization Review / Veterans Service Representative (VSR)
• Facility Type: Administrative Government Office / Tertiary Care Teaching Hospital
• Position Type: Permanent
Responsibilities:
• Employment duties include the following benefit programs and entitlement criteria, analyzes claims material, identifies issues, gathers relevant evidence, conducts interviews to adjudicate claims, and inputs data necessary to generate the award and notification letter to the veteran describing the decision. Making determinations as to the eligibility for the type of benefit sought to include questions relating to adequacy of military service, medical evidence, and the evaluation of evidence of income, employability, dependence, and relationship. Requests examinations, re-examination, or opinions to evaluate disabilities resulting from diseases or injuries. Reviews claims cases to assure all issues have been addressed, applies, and interprets VA laws, including veterans' case law, existing statutes and procedures, precedent rulings, and state law in the adjudication process. conducts interviews in person or by phone with veterans, representatives, and advocates to explain the full range of VA benefits and related programs. Prepares and releases correspondence for use by other federal, state, and local agencies. Utilizes various electronic data processing (DEPP) systems to input data for processing claims and generating automated correspondence. Applied case management skills by assessing Veterans' physical and mental wellness, needs, preferences, and abilities, using these to develop tailored care plans to provide positive outcomes for Veterans and their families. Provided transitional care by scheduling examinations with civilian medical contractors
Facility: Bay Pines VA Hospital, Tampa, FL 12/2022-03/2023 Job title: RN Utilization Review / Advanced Medical Support Assistant
• Facility Type: Short-Term Acute Care Teaching Hospital
• Position Type: Travel
• Bed Count: 499
• Trauma Level: I
Responsibilities:
• Employment duties included the following: collaboration and communication with a wide range of medical clinicians across multiple disciplines (e.g., medical doctors, nurse practitioners, physician assistants, psychologists, psychiatrists, social workers, clinical pharmacists, and nursing staff) to accomplish team goal setting to ensure medical care to patients is met. Set priorities and organize work to meet deadlines, ensuring compliance with established processes, policies, and regulations. Communicate tactfully and effectively, electronically, by phone, in person, and in writing, with internal and external customers. Prepared reports in various formats and presented data to various organizational levels, as well as resolved patient concerns. Provided advanced knowledge of the following: technical health care process including, but not limited to, scheduling across interdisciplinary coordinated care delivery and/or care in the community models and patient health care portals as it relates to access to care, policies and procedures associated with interdisciplinary coordinated care delivery and/or care in the community operational activities that affect patient flow, and patient support care administrative functions included, but not limited to appointment cycles, outside patient referrals, follow-up care, overbooking, provider availability, etc. Possess advanced knowledge of medical terminology due to the technical nature of the language utilized by clinicians. Provided case management services via phone by following up with discharged Veterans to ensure they were satisfied with services and that they are still in good physical and mental health
Facility: Optum Health Care, Tampa, FL 10/2021 - 03/2023 Job title: RN Utilization Review / Healthcare Support Contract Care Advocate (WIT Special Project Clinical Team)
• Facility Type: Diversified Health Services and Technology Firm
• Position Type: Travel to PRN
Responsibilities:
• Responsible for the review and summarization of 67,000 cases involving Mental Health Parity and the Wit v. UBH Class Action Lawsuit. Primary Responsibilities: Review of clinical case management, utilization and review of behavioral health and substance abuse cases. Review of select facility-based admissions for mental health and substance abuse, made benefit determinations about appropriate levels of care using nationally approved clinical guidelines, (LOCUS, CASII, ECSII and ASAM Criteria for determining medical necessity) identified cases and prepared them to be sent for peer review with the Medical Director pertaining to the Wit v. UBH Class Action Lawsuit. Provided guidance and direction on survey issues to state agency (SA) staff.
Facility: Zentech Medical Staffing, Tampa, FL 08/2021 - 10/2021 Job title: RN Utilization Review / Registration and Injection Nurse
• Facility Type: Medical staffing and Healthcare recruitment agency
• Position Type: Local Contract
Responsibilities:
• Provides nursing care following established policies, procedures, and protocols of the organization and administration of monoclonal antibodies both intravenous and subcutaneous injection for the prevention of hospitalization due to COVID-19 infection. Monitors vital signs record and communicate patient condition as appropriate utilizing computerized documentation systems. Instructed and educated patients concerning COVID-19 signs and symptoms. Analyzed statistical and historical data, cleans, and reports data to assess state agency (SA) effectiveness in the survey process, and recommended improvements. Employment Gap 05/2021 - 07/2021
Reason: Personal time off
Facility: Healthcare Support Staffing, Tampa, FL 12/2020 - 04/2021 Job title: Contract Nurse Reviewer/Case Manager
• Facility Type: Healthcare staffing agency and Medical recruitment firm
• Position Type: Remote
Responsibilities:
• Utilizes clinical nursing and case management skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. Reviews work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding, along with analysis and processing of Medicare claims. Well-versed in healthcare billing and coding practices, coding systems for medical services. Proficient with healthcare delivery systems, medical bill processing systems, as well as instructing healthcare providers and other stakeholders regarding medical billing and coding requirements. Formulated, recommended revisions or changes to existing program policies, criteria, standards, and procedures.
Facility: Care Centrix, Tampa, FL 04/2020 - 11/2020 Job title: Nurse Reviewer/Case Manager
• Facility Type: Ancillary care management and post-acute home care services coordination company
• Position Type: Remote
Responsibilities:
• Performs utilization review activities, including precertification and retrospective reviews, according to guidelines. Determines the medical necessity of requests by performing first-level reviews using approved evidence-based guidelines/criteria. Answers Utilization Management directed telephone calls; managing them in a professional and competent way. Refers cases to reviewing physician when the treatment request did not meet the necessity per guidelines, or when guidelines were not available. ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding, along with analysis and processing of Medicare claims. Experienced with monitoring payments, payment systems, billing, and coding to identify and make recommendations on potential weaknesses in payment systems. Employment Gap 03/2020 - 03/2020
Reason: Personal time off
Facility: EXL Healthcare, Tampa, Fla 08/2019 - 02/2020 Job title: Nurse Consultant/Case Manager
• Facility Type: Operations center for Clinical Care Management, Healthcare Analytics, and Payment Integrity Solutions
• Position Type: Remote
Responsibilities:
• Nurse Consultant Functional Responsibilities: Manages assigned caseload of complex cases; applies specialized training/knowledge to the assessment of cases; provides technical insight and advice. Reviews, records, and analyzes medical records and treatment plans data to make claims settlement determination; compares duration control guidelines and clarifies functional inconsistencies; provides recommendations to team regarding employee’s current or potential functional abilities; develops goal-focused return-to- work plans; addresses barriers for return to work; facilitates communication between employee, physician and employer and partners with all parties to achieve a positive outcome. Follows established claim policies and practices to resolve claims and issues. Performs other related duties as assigned or required. Responsible for correlating the job duties, functional capability and the definition of disability per contact. Assess medical records and treatment plans for all STD/LTD/FML claims, comparing duration control guidelines and clarifying functional inconsistencies in order to determine residual abilities. Provides recommendations regarding the claimants’ current or potential functional abilities and develops a goal- focused return to work plan. Provides education on medical and disability issues for all STD/LTD/FML Claim Specialists. Skilled in communicating findings, evaluations, problem resolution, and recommendations with national-level management, staff, outside experts, and health care providers. Applied case management techniques to evaluate clients’ progress periodically and making adjustments as needed to provide positive outcomes for clients
Employment Gap 07/2019 - 07/2019
Reason: Personal time off
Facility: Windmoor Healthcare (Psychiatric Hospital), Clearwater, FL 04/2019 - 06/2019 Job title: Charge Nurse/Float
• Facility Type: Freestanding, Private For-Profit Behavioral Health and Psychiatric Hospital
• Position Type: Travel
• Bed Count: 144
Responsibilities:
• Member of the code team. Responsible for performing administrative tasks, charting, and assessment of psychiatric patients to include the Colombia Suicide Risk Assessment. Makes resources available to the doctors and the patients to ensure proper functioning of the unit. Completes staffing and patient assignments. Provides comprehensive mental/behavioral health care, including primary care integration to a complex patient population in the outpatient setting. Passing medications and performing basic and complex nursing care.
Facility: Valforce Healthcare Staffing - Pinellas Park, FL 08/2018 - 04/2019 Job title: Contract Nurse Case Manager
• Facility Type: Government/military administrative medical center
• Position Type: Travel
Responsibilities:
• Responsible for providing services in support of Individual Medical Readiness to the US Army Reserve Regional Support Commands (RSC) and Medical Management Activity (MMA) as well as a wide range of Case Management support services to Soldiers found to have medical/behavioral health issues or concerns that are medically not ready for mobilization/training and require referral management for care/treatment or for appropriate medical board. Reviewed and prepared documentation of mental health disorders that ranged from depression to PTSD. Military workmen’s compensation component of case review (Profile Request Packets).
Facility: Aetna - Tampa, FL 05/2017 - 08/2018
Job title: Utilization Review Nurse Consultant
• Facility Type: Regional corporate office / administrative operations.
• Position Type: Permanent
Responsibilities:
• Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates with the clinical resolution with internal/external clinician support as required. ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims
Facility: United Healthcare- Oldsmar, FL 12/2013 - 05/2017 Job title: Utilization Review Nurse
• Facility Type: Health Insurance Payer Operations / Corporate Utilization Management (UM) and Review Center
• Position Type: Permanent
Responsibilities:
• Responsibilities include Concurrent Review (on-site or telephonic Inpatient Care Management). Performs reviews of current inpatient services. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Reviews medical records and prepare clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. Apply an understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review nurse works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings. ICD- 9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims.
Facility: Coventry Healthcare - Tampa, FL 05/2012 - 12/2013 Job title: - Pre-Authorization Nurse/Case Management
• Facility Type: Managed Care Organization / Corporate Workers' Compensation and Health Insurance Administration Hub
• Position Type: Permanent
• Trauma Level: I
Responsibilities:
• Responsibilities include assisting providers to the Plan's authorization review procedures, working closely with physicians to secure information necessary for utilization management and implementing / documenting utilization management activities which incorporate a thorough understanding of clinical knowledge and appropriateness of medical services related to effective cost containment. Other duties include assuring the medical necessity / appropriateness of the delivery of healthcare resources provided to members as per their benefit package, through medical review of inpatient / outpatient service requests and utilizing established Medical Director Guidelines to approve claims. Tasks also encompassed participating in the negotiation / notification processes that results from medical record reviews, preparation of notification letters for denial of services, offering alternatives to patients requiring interventions prior to their hospitalization. Other job functions include negotiating transitional levels of care for service requests, authorizing hospital admissions / diagnostic testing / ambulatory services. Conducted onsite inspections of health care delivery provided to beneficiaries to evaluate the quality of care, quality of life, and the provision of other services.
**ADDITIONAL EXPERIENCE AVAILABLE UPON REQUEST**
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