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Yyyyyy x. yyyyyy

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

 

Driven, focused, and hard-working Case Manager with 15+ years of experience in nursing and administrative roles along with an exceptional educational background which includes a Master s Degree in Nursing. Experienced in managing cross-functional teams, supporting complex patient cases, completing utilization review functions, and ensuring compliance with federal/state regulations. Highly adept in improving operational efficiency levels in addition to maintaining strong communication with others.

 

Key Competencies

 

Utilization Management/Review Team Leadership Program Management Case Management

Electronic Medical Records Attention to Detail Report Generation Milliman s Criteria Guidelines

Process Improvement EPIC/Microsoft Office Certified Professional Coder Certified Case Manager

 

Professional Experience

Optima Health, Virginia Beach, VA August 2010-Present

Integrated Case Manager (2012-Present)

  Direct day to day case management logistics within a fast-paced medical environment with a focus on increasing productivity and patient care quality

  Work closely with medical teams in order to successfully utilize evidence based practices, ensure regulatory guidelines are followed, and implement innovative workflow processes

  Support the training of new hires within the department, coach internal/external teams on health care plans and/or options, and perform detailed case reviews

  Complete utilization reviews for the Ohio Healthy Plan, generate detailed case presentations, enter pre-authorization requests, and negotiate pricing with out of network providers

 

Clinical Claims Reviewer (2010-2012)

  Coordinated the review and processing of claims within a busy medical facility which centered on ensuring appropriate payment of claims and processing denied claim reconsideration requests

  Accurately coded fees for multiple surgeries and various modifiers in addition to working closely with Medical Directors and other medical team members

  Led the generation of denial for payment letters, updated patient/case files, and maintained positive relationships with internal/external patients

 

Gastroenterology Associates June 2002-May 2009

LPN/RN

  Supported nursing and administrative functions which included performing detailed patient exams, obtaining comprehensive medical histories, and assisting in medical procedures

  Supervised administrative staff members, generated CQI reports on a quarterly basis, trained new staff members, and monitored patients after endoscopic procedures

  Reviewed patient lab requests, called prescriptions into pharmacies, scheduled patient follow-up visits, and utilized the CARIS system to generate pathology requisitions

 

Additional Professional Experience Includes: RN, Sentara Bayside Hospital (2007) and LPN, Atwood Family Medical Center (2001-2002)

Education & Certifications

 

Master of Science, Nursing, American Sentinel University, Aurora, CO (September 2017, 4.0 GPA)

Bachelor of Science, Nursing, American Sentinel University, Aurora, CO (4.0 GPA)

Nursing Diploma, Riverside School of Professional Nursing, Newport News, VA

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