Experience

Alignment Health

• United States
• Hospitals and Health Care
• 500 - 600 Employee

• Delegation Oversight Nurse Auditor

  • May 2021 - Present



WellCare Health Plans

• United States
• Insurance
• 700 & Above Employee

• Appeals Review Nurse - January 2018 - May 2020

  • May 2014 - May 2020

  • Evaluate the medical necessity and clinical appropriateness of services. • Review all appeals and provide direction to coordinator on what information to obtain for use in appeal review. • Outreach to provider, IPA, vendor etc. for additional information as needed. • Adhere to timeliness standards for processing appeals. • Identify and apply clinical coverage guidelines based on submitted information (Milliman (MCG) and Interqual). • Use clinical expertise to compare… Show more • Evaluate the medical necessity and clinical appropriateness of services. • Review all appeals and provide direction to coordinator on what information to obtain for use in appeal review. • Outreach to provider, IPA, vendor etc. for additional information as needed. • Adhere to timeliness standards for processing appeals. • Identify and apply clinical coverage guidelines based on submitted information (Milliman (MCG) and Interqual). • Use clinical expertise to compare information from established guidelines and plan benefits against medical records and notes provided to issue a clinical coverage decision for approval. • Develop a case summary and recommendation for the Medical Director using standardized templates and forms. • Makes administrative appeal determinations. • Applies regulatory requirements and accreditation standards to all review activity and reporting. • Applies accepted criteria to review process, utilizes the parameters and inputs review data into system. Show less • Evaluate the medical necessity and clinical appropriateness of services. • Review all appeals and provide direction to coordinator on what information to obtain for use in appeal review. • Outreach to provider, IPA, vendor etc. for additional information as needed. • Adhere to timeliness standards for processing appeals. • Identify and apply clinical coverage guidelines based on submitted information (Milliman (MCG) and Interqual). • Use clinical expertise to compare… Show more • Evaluate the medical necessity and clinical appropriateness of services. • Review all appeals and provide direction to coordinator on what information to obtain for use in appeal review. • Outreach to provider, IPA, vendor etc. for additional information as needed. • Adhere to timeliness standards for processing appeals. • Identify and apply clinical coverage guidelines based on submitted information (Milliman (MCG) and Interqual). • Use clinical expertise to compare information from established guidelines and plan benefits against medical records and notes provided to issue a clinical coverage decision for approval. • Develop a case summary and recommendation for the Medical Director using standardized templates and forms. • Makes administrative appeal determinations. • Applies regulatory requirements and accreditation standards to all review activity and reporting. • Applies accepted criteria to review process, utilizes the parameters and inputs review data into system. Show less



Easy Choice Health Plan

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Nurse Case Manager / Utilization Management / Transitional Care - May 2014 - December 2017

  • May 2014 - May 2020

  • Coordinates the care and services of selected member populations across the continuum of illness. • Promotes effective utilization and monitors health care resources. • To assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Members. • Interacts continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status. • Assess the options… Show more • Coordinates the care and services of selected member populations across the continuum of illness. • Promotes effective utilization and monitors health care resources. • To assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Members. • Interacts continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status. • Assess the options for care including use of benefits and community resources to update the care plan. • Acts as liaison and member advocate between member/family, physician, and facilities/agencies. • Coordinates community resources with emphasizes on medical, behavioral and social services. • Applies case management standards and confidentiality of protected health information. • Reports critical incidents and information regarding equality of care issues. • Outreach to members telephonically and coordinates member's case management services. • Requests consultation and diagnostic reports from network specialist. • To reduce the unnecessary/preventable hospital readmissions by making sure that our members have a smooth transition from the hospital to their homes or extended care facilities. • To reach out to member/family to identifies any issues that may potentially cause readmission. Show less • Coordinates the care and services of selected member populations across the continuum of illness. • Promotes effective utilization and monitors health care resources. • To assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Members. • Interacts continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status. • Assess the options… Show more • Coordinates the care and services of selected member populations across the continuum of illness. • Promotes effective utilization and monitors health care resources. • To assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the Members. • Interacts continuously with member, family, physician(s) and other providers utilizing clinical knowledge and expertise to determine medical history and current status. • Assess the options for care including use of benefits and community resources to update the care plan. • Acts as liaison and member advocate between member/family, physician, and facilities/agencies. • Coordinates community resources with emphasizes on medical, behavioral and social services. • Applies case management standards and confidentiality of protected health information. • Reports critical incidents and information regarding equality of care issues. • Outreach to members telephonically and coordinates member's case management services. • Requests consultation and diagnostic reports from network specialist. • To reduce the unnecessary/preventable hospital readmissions by making sure that our members have a smooth transition from the hospital to their homes or extended care facilities. • To reach out to member/family to identifies any issues that may potentially cause readmission. Show less



Affiliated Doctors of Orange County

• Nurse Case Manager

  • Jun 2013 - May 2014



Seacliff Rehabilitation Center

• Huntington Beach, CA

• Minimum Data Set (MDS) Nurse

  • Nov 2010 - Jul 2013