Experience

Health Partners Plans

• United States
• Hospitals and Health Care
• 300 - 400 Employee

• Clinical Stars-Hedis Nurse Audit Specialist

  • Nov 2016 - Present

  Conducts quality medical record review to ensure continuum of care management effectiveness and to report to the PCP potential gaps and adherence issues against clinical, HEDIS, STARs and other regulatory objectives. Identifies quality related issues, recommends possible solutions and collaborates with the provider offices to implement an oversight/improvement program to ensure deficiencies are addressed and processes are put in place to ensure future compliance. Provides analysis, tracking, and trending reports to the HCM management team identifying deficiencies found during reviews for the purpose of improving quality. Assists with the development and execution of core provider education programs including, disease based and complex case management, pre-certification, utilization review and customer service.



Health Partners/Medical staffing Network

• Hedis Nurse Auditor

  • 2016 - 2016

  Conducts on-site reviews at participating provider offices to assess environment, quality of physicians medical records, and compliance with documentation standards. Prepares appropriate documentation to summarize on-site findings with physician, providing education and discussing opportunities for improvement. Provides data support services to facilitate the process and analyze trends/patterns for quality improvement and health management. Assists the Quality Management department with various special projects and focused clinical studies.



Seacrest Village Nursing and Rehab

• Floor Nurse

  • 2015 - 2016

  Responsible for medication administration for the Skilled Nursing residents in compliance with Federal & State regulations and Senior Lifestyle Corporation guidelines.Responsible for the admissions of new resident to include all admission assessments and documentation.Responsible for completing acute and long term care plans.Provides general consultation regarding health related concerns within the community.Notifies physicians and/or family members of any change in resident's health and provides proper documentation



Rowan University

• Higher Education
• 700 & Above Employee

• Multiple Sclerosis Nurse Educator

  • Feb 2013 - Mar 2015

  Provides Direct Case Management to patientsReimbursement and prior authorization assistance for medication and In-home/outpatient services Provides education and Initiation of treatment for patients on chronic medication Follow up with patients to ensure treatment adherence Remotivation for treatment continuation, general requests from patientsReporting to doctors on patient progress and on adverse eventsEmpowering patients with information, support and advice about disease, from diagnosis throughout treatment durationPatient data review and managementStrong understanding of the autoimmune disease process Strong understanding of quality and regulatory policies, processes and environment



Bravo Health/Cigna

• Nurse Case manager

  • Aug 2009 - Dec 2012

  Provides Telephonic Case Management to assigned members Develops an individualized plan of care and implements the plan Communicates with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member Coordinates with member, family, and caregivers to help resolve barriers to care Provides Telephonic Case Management to assigned members Develops an individualized plan of care and implements the plan Communicates with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member Coordinates with member, family, and caregivers to help resolve barriers to care



Cancer Treatment Centers of America (acquired by City of Hope)

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Care Manager

  • 2008 - 2009

  Responsible for the coordination of all systems/services required for an organized, multidisciplinary team approachAdvocate and contact person for patient, family, healthcare team members, employees and outside agencies Providing and assuring continuity of care and optimal clinical and resource outcomes are achieved. Provides prompt response to telephone inquiries and assisting with drop in patients to the department and other issues of a clinical nature as requested Responsible for the coordination of all systems/services required for an organized, multidisciplinary team approachAdvocate and contact person for patient, family, healthcare team members, employees and outside agencies Providing and assuring continuity of care and optimal clinical and resource outcomes are achieved. Provides prompt response to telephone inquiries and assisting with drop in patients to the department and other issues of a clinical nature as requested



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• Utilization Management Nurse

  • 2007 - 2008

  Utilization Management , 2007-2008Rendering initial determinations of medical appropriateness for communication to the health benefit planObtain appropriate information from health care provider and/or patient or family regarding planned procedure, admission, continued stay or discharge planComplete all medical necessity reviews and communicate outcomes to providers within the appropriate time framesIdentifying individuals whose health and/or expense may be positively affected through application of Large Case ManagementParticipates in a collaborative team approach and works independently, as well as cooperatively and collaboratively with health care staff and managementFacilitates optimum reimbursement through accurate certification and complete chart documentation Completes admission and continued stay reviews based on UR criteria.



Aetna US Healthcare, King of Prussia, PA

• Inpatient Care Nurse Consultant/Case Manager

  • 2006 - 2007

  Utilizes clinical skills in a collaborative process that helps to assess, plan, coordinate, and evaluate services and options for appropriate inpatient healthcare managementObtain information from providers and facilities concerning the care being provided to members. Use of strong customer service skills to coordinate service deliveryAssessment of a member's clinical condition and medical services and ongoing treatments to determine medical appropriateness and Medical intervention Use of Internet, word processing and database software Facilitate discharge to the appropriate setting for discharge planning and coordination with knowledge of Utilization review/Managed care



Magee Rehabilitation Hospital

• Staff Nurse

  • 2002 - 2006

  Provided care to patients with neurological disorders, spinal cord injuries and post orthopedic surgeries from 17 years of age to adulthood Administration of medications and Documented information into CPSI computerized systemCollaborated with physicians and health care team to provide optimal patient careContributed to implementation and evaluation of policies related to the nursing practice within employment setting. Provided care to patients with neurological disorders, spinal cord injuries and post orthopedic surgeries from 17 years of age to adulthood Administration of medications and Documented information into CPSI computerized systemCollaborated with physicians and health care team to provide optimal patient careContributed to implementation and evaluation of policies related to the nursing practice within employment setting.



Cooper University Health Care

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Staff Nurse

  • 2004 - 2005

  Provided emergency care in a Level 1 Emergency Department.Triaged and evaluated patients emergent medical needs Recommended expedited admission and/or discharge to the appropriate service areas of the hospitalProvided assistance to the research department, participating in research studies, helping in data collection and patient enrollmentAdministrated medications, obtained blood samples, provided wound care, Assisted with minor surgical procedures and OBGYN examsInitiated and monitored IV therapy, provide patient teaching on admission and Discharge.



Children's Hospital Colorado

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Staff Nurse

  • 2003 - 2004

  Provides pt. care to patients ranging from birth to twenty years of age on a 14 bed unit. Administration of medications to patients by mouth, intramuscularly and subcutaneous routes.Providing orthopedic care as well as providing care for patients not requiring greater in-depth or follow up care.Utilize computer to order and enter laboratory tests, x-rays and discharge instructions. Interacting with doctors and staff to provide patient care. Provides pt. care to patients ranging from birth to twenty years of age on a 14 bed unit. Administration of medications to patients by mouth, intramuscularly and subcutaneous routes.Providing orthopedic care as well as providing care for patients not requiring greater in-depth or follow up care.Utilize computer to order and enter laboratory tests, x-rays and discharge instructions. Interacting with doctors and staff to provide patient care.