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0000 xxxxxx xxxx , xxxx , xxxxx 00000 xxx-xxx-xxxx ● firstname.lastname@example.org
Assessments Care Plan Management Patient Relations
Utilization Management Quality Management Regulatory Compliance
Effectively cooperate with patients, healthcare management companies, insurance companies, and other third-party payers to determine, coordinate, and deliver quality, cost-effective care.
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 plans throughout claim life cycle.
Draw upon outstanding clinical judgment to make sensible decisions which promote patient health while ensuring resources are available to those most in need.
Possess a strong blend of assessment, administrative, communication, and documentation skills.
Proficiency with complex medical cases, Workers Compensation, and accident-related injury cases.
Clinical skills span medical-surgical, oncology, cardiology, community health, and IV/phlebotomy.
Brookhaven Memorial Hospital Medical Center, 2011 to Present
Spearhead full-scope care management for adult inpatients with multiple chronic and acute conditions and injuries spanning Telemetry, Medical-Surgical, and Emergency Room floors.
Screen and assess patients at time of admission, steadily monitor progress throughout treatment plan, and facilitate all aspects of discharge planning.
Manage utilization review of medical services across continuum of acute care and subsequent transition into community.
Leverage Patient Review Instrument (PRI) to identify eligibility for skilled nursing care placement.
Promote cohesive communication and collaboration among multidisciplinary team members and other service providers to optimize patient outcomes.
Serve as member of Utilization Review Committee and Case Management Improvement Group.
Conduct quality audits on documentation to ensure strict adherence to DOH regulations.
Americhoice / United Health Care, 2007 to 2010
Field-Based / Telephonic Clinical Complex Case Manager
Charged with overseeing Medicaid/Medicare cases involving aging populations affected by multiple chronic and acute conditions and injuries.
Thoroughly assessed members' needs, compiled care plans, and employed sharp organizational skills to coordinate referrals, home care services, various therapies, physician visits, HHA hours, and DME.
Provided comprehensive patient education, performed diligent follow-up, traveled to doctor's offices, and participated in rounds with team and medical director.
South Nassau Communities Hospital, 2007 to 2012
Inpatient Case Manager (per diem)
Administered concurrent and retrospective reviews involving Medicaid, Medicare, Managed Care, and private plans while closely partnering with physicians to achieve optimal use of acute care resources.
Systematically steered discharge planning in tandem with social workers and proactively arranged linkages with appropriate community-based services.
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Care Manager Inc., 2006 to 2007
Field Case Manager (per diem)
Delivered case management services for Medicare/Oxford/United Healthcare members identified with Level III clinically complex medical conditions.
Leveraged CareOne/Evercare tool to assess patients, coordinated home care and PCP/specialist interventions, provided follow-up care, and re-assessed interventions to ensure alignment with goals.
Concurrently served as consulting RN Case Manager with Amerigroup.
Intracorp/Cigna, 2005 to 2006
Field Nurse Case Manager
Conducted medical, vocational, financial, and behavioral needs assessments for disabled clients, prepared rehabilitation plan, coordinated plan of care, and performed monthly progress tracking.
Prudently advised supervisory team in concerns or complaints expressed by providers, injured workers, and customers to mitigate risks and ensure injured worker's safety.
1199 National Benefit Fund, NY, NY, 2004 to 2005
Telephonic Nurse Case Manager
Demonstrated exemplary talents in caseload management across the life cycle and encompassing a broad range of medical and surgical maladies.
Participated in discharge planning, closely monitored patients through acute and subacute placement, and arranged home care services, social work interventions, and DME supplies as deemed eligible.
Jordan Rehabilitation Services, Inc. Westbury, NY, 1998 to 2004
Nurse Case Manager / Medical Audit Specialist
Helmed complete spectrum of case management for individuals disabled by accident or work-related injury, and facilitated timely discharge from hospital or rehab to home care.
Conducted in-depth home and hospital assessments, attended physicians visit, arranged vocational rehabilitation, negotiated fees for services, and led physician review and claims appeal processes.
Performed utilization review of ongoing acute inpatient & outpatient medical-surgical, psychiatric, rehabilitation, and home care.
Methodically audited medical, hospital, and surgical CPT/ICD-9 coding and billing records.
Generated chart review and written narrative summaries for No-Fault cases, catastrophic cases, liability litigation, and claims payment.
Interim Health Care, Mineola, NY, 1998 to 1999
Community Health RN (per diem)
Provided direct patient care to homebound patients including nursing assessments, delegating tasks to home care aides, providing case management services, and coordinating multidisciplinary teams in discharge planning and referrals to specialty care.
North Shore University Hospital, Manhasset, NY, 1997
Patient Care Coordinator / Medical-Surgical Float Team RN
Effectively cared for patients with neuro, orthopedic, vascular, gynecological, cardiac, and other post-op conditions as well as oncology, CVA, COPD, diabetes, ESRD, AIDS, and TB/infectious disease.
Applied polished clinical skills in managing IVs, central lines, EKGs, arrest codes, tube feedings, TPN, blood/blood product transfusions, peritoneal dialysis, chest tubes, drains, CAPD, hemodynamic monitoring, PCA/pain management, and ostomy/wound care.
BSN, Adelphi University, Garden City, NY
Hospital and Community Patient Review Instrument (H/C PRI) and SCREEN Certification
BCLS and AED Certifications
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