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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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