Yyyyyy x. yyyyyy

0000 xxxxxx xxxx , xxxx , xxxxx 00000 xxx-xxx-xxxx ● abc@xyz.com

Claim Analysis ~ Team Collaboration ~ Decision-Making ~ Report Writing

         Excel at providing high-quality and cost-effective nurse case management services.

         Proven success in guiding, closely monitoring, and ensuring timely clinical transition of patients through medically appropriate levels of care.

         Adept at evaluating and updating treatment and return-to-work (RTW) plans throughout claim life cycle.

         Draw upon outstanding clinical judgment to make prudent decisions which promote patient health while ensuring resources are available to those most in need.

         Possess a strong blend of assessment, negotiating, communication, and documentation skills.

         Effectively cooperate with patients, healthcare management companies, insurance companies, or other third-party payers to determine and coordinate quality, cost-effective care.

Optum/United HealthCare, 2005-2017

Nurse Case Manager

         Managed Worker s Compensation/injury/auto/liability cases within states of New York and New Jersey.

         Leveraged substantial knowledge of ancillary services, DME, diagnostics, and pharmaceutical programs to optimized cost-effective measures for the insured.

         Sole designated bilingual Nurse Case Manager for North Jersey territory for last seven years.

         Achieved RTW goals within ODG guidelines for over 90% of assigned cases to result in excellent overall cost savings to the insured and employer.

         Monitored patient progress towards desired outcomes through ongoing assessment and evaluation.

Procura Management Inc., 2005-2015

Senior Bilingual Nurse Case Manager

         Coordinated and attended medical evaluations with health providers for Worker s Compensation cases within New Jersey territory, and actively assisted with New York Worker s Compensation cases when requested.

         Leveraged training in hospital audits to facilitate Worker s Compensation and auto no-fault claims.

         Applied strong leadership talents toward training, mentoring, educating, and coaching new case managers.

         Arranged specialty referrals, consultations, and services in alignment with clinical guidelines to expedite recovery and RTW.

ADP Claims Solution Group, 2004-2005

Case Management Specialist II

         Promoted to senior position based on proven expertise in closely monitoring medical care received by claimants and seamlessly liaising between account, provider, and claimant.

         Arranged and attended medical evaluations, physician s appointments, physical therapy and diagnostic imaging, coordinated home health care, and arranged for transportation when necessary.

Quality Review Systems, 1999-2004

Field Nurse Case Manager

         Independently managed both Worker s Compensation and auto no-fault files for multiple insurance companies throughout NY, NJ, and PA territory.

         Assembled preferred provider list of specialists knowledgeable in Worker s Compensation regulations to facilitate treatment plans which result in achieving specific RTW targets.

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Corvel, 1998-1999

Field Nurse Case Manager

         Planned, delivered, and documented telephonic and field case management for New York tri-state area.

         Methodically conducted client assessments and steered patient care process from initial hospitalization through rehabilitation and return to work.

         Efficiently functioned as liaison between claims adjuster, physician, and claimant to expedite medical recovery at minimum expense to Corvel.

Maimonides Medical Center, 1997-1999

Staff Nurse, Med-Surg Unit

         Cared for patients on 40-bed unit affected by cardiac, oncology, CVA, COPD, diabetes, ESRD, AIDS, TB/infectious disease, ortho & neuro problems, psychiatric, and other medical and post-op conditions.

         Exhibited outstanding clinical proficiency with vents, trachs, IVs, central lines, cardiac/pulse oximetry monitoring, tube feeding, TPN, chest tubes and drains, peritoneal dialysis, PCA/pain management, ostomy care, and wound care.

         Provided family teaching and compassionate emotional support for terminally ill patients.

         Assessed and admitted patients, created care plans for patients across the age spectrum, and performed comprehensive charting to ensure stringent compliance with JCAHO policies and other regulations.

         Proactively coordinated unified efforts among multidisciplinary teams (social workers, PT/OT, physicians, pharmacists, and dieticians) to streamline discharge process for patients.

Witco Corporation, 1992-1998

Compensation Specialist and Safety Coordinator / Emergency First Aid Responder

         Efficiently provided full-scope case management services for Worker s Compensation and other industrial injury cases.

         Meticulously documented incidents, monitored and followed up on cases to expedite RTW, and actively assisted in administering onsite semi-annual employee physicals.

         Systematically conducted quality audits to ensure rigorous compliance with ISO9000 standards.

         Facilitated monthly safety meetings and prepared safety/first aid tests to measure staff comprehension and compliance.

         As Safety Coordinator, provided emergency first aid, medical triage, stabilization, and transport for up to 140 industrial employees.

BS, Nursing, Long Island University, 1995

BS, Psychology, Brooklyn College, 1992

RN license NY and NJ

CCM

Hospital Auditing

Life Care Planning

URAC

CPR / First Aid

Case Management

Phlebotomy