Worker's Compensation Case Manager
Mar 2014－Aug 2014
The Reny Company
In office telephonic worker's compensation case manager and preauthorization nurse. Responsible for responding to FROI within seven minutes of injury report from client. Contacted urgent care center to determine IW current status, ask for any work restrictions, and fax request for medical records. Also contacted safety supervisors for update on IW condition. Upon receipt of medical records, made appropriate arrangements for IW to be seen by the correct specialist for the specific injury. Contacted network medical providers to arrange medical appointments as soon as possible. Contacted IW to provide name of treating physician as well as time, date, and location of initial appointment. Obtained medical records after initial consult and proceeded to make arrangements with specialists and hospitals when surgery was required. Reported all updates to Work Comp Insurance Carrier Client to keep them appraised of IW condition and anticipated return to work status. Contacted employers to determine if any modified duty positions were available in certain cases. Maintained Excel spreadsheet of status of all workers and provided end of month report to client. Maintained telephonic case management contact for all IWs who were not released immediately after initial injury and did not return to work within the expected time frame per ODG. Continued ongoing open communication with all parties was essential to a timely return to work process.
Preauthorization nurse for eight worker's comp clients. Received requests for treatment of IW from treating physicians and therapists via phone, fax, and email. Reviewed medical records and utilized ODG guidelines to determine if a certification for treatment could be made at the first level or if the request needed to go to second level review by the medical director. Handled concurrent, retro, rush, and appeal reviews. For concurrent reviews, adhered to three day turn around time frame as dictated by company policy. All determinations were returned in a timely fashion via fax or email. Fielded all incoming phone calls regarding status of requests. Prepared end of month invoice reports for each client and presented them to the company owner for review. After all reports were reconciled then each individual determination was entered into the appropriate computer data base. Other responsibilities included occasional line item billing review to determine which charges were work injury related or not and writing a report to support the findings.
Utilization Review Nurse
Jul 2013－Jan 2014
Contract position with AIG. Preauthorization review of all incoming treatment requests for IWs for the state of California. Conducted thorough review of attached medical records and utilized guidelines of ODG, ACOEM, and CAMTUS to complete first level certification of requests or if unable to approve, prepared medical record review report for forwarding to medical directors for second level review and determination. Adhered to California state guidelines for all requests and appeals. Maintained a case load of 70-90 requests per day which required a very faced pace and accurate process of moving cases throughout the day without delay. All final determination results were faxed or phoned back to the requesting party within the appropriate time frame.
Telephonic Case Manager
Oct 2012－May 2013
In office telephonic case manager registered nurse. Reviewed authorization activity and claim reports to recommend placement in case management as indicated by a comprehensive patient assessment. Responded to requests from payors and providers to evaluate individuals for the case management program. Developed a plan of care in conjunction with the patient, their significant other, provider, and payor. Implemented a plan of care for individuals in inpatient, home, rehabilitation, and/or skilled nursing settings. Transitioned those patients to the appropriate level of care by coordinating services and obtaining vocational or psychological assessments to plan and implement the appropriate level of care. Functioned as patient advocate by educating them regarding their condition and the navigation of the health care system. Completed monthly reports for the payors to indicate the cost benefits of the case management services.
Disease Management Registered Nurse
Nov 2011－Oct 2012
Inventiv Medical Management
Remote telephonic disease management and outreach for eligible insured members to conduct comprehensive wellness education for five core conditions including: Asthma, Coronary Artery Disease, Diabetes, High Cholesterol, and Hypertension. Worked in partnership with member health plans to ensure employee compliance with health lifestyle changes. Coached members on benefits of smoking cessation as well. Conducted a call to an employee who wound up being the CEO of one of our contracted hospitals. He revealed his identification at the end of the call. He was very complimentary of my professionalism and sent a letter to my manager to compliment a job well done. Consistently met or exceeded daily call attempts and successful coaching contact quotas.
Telephonic Nurse Educator
Nov 2010－Apr 2011
Telephonic outreach and education to patients receiving Exjade as an oral iron chelator for iron overload due to the chronic need for blood transfusions. Provided extensive education on the proper preparation and ingestion of the medication. Emphasized the importance of compliance with the medication regime, the management of adverse side effects, and the importance of preventing iron overload as it affects multiple internal organs if left untreated.
Telephonic Health Coach Registered Nurse
Dec 2007－Jun 2009
Health Dialog Incorporated
Telephonic outreach to insured members with chronic health conditions such as coronary artery disease, chronic obstructive pulmonary disease, asthma, diabetes, and congestive heart failure. Teaching focus was on the promotion of healthy lifestyle changes, compliance with treatment plans, and preventive care. Inbound telephonic triage symptom response calls were conducted utilizing clinical protocols and algorithms to guide the advice given to the caller. Strict adherence to HIPPA confidentiality guidelines and maintenance of all CEU requirements while licensed in all 50 states.
Telephonic Registered Nurse Case Manager
Sep 2002－Jul 2005
United Health Group
Reviewed member specific insurance policy parameters to help determine appropriate in network services based on the individual member's medical needs both inpatient and outpatient. Determined medical appropriateness of inpatient and outpatient services based on medical guidelines and benefit determination with the ability to translate those policy provisions to the insured member. Experience with explaining to insured members who were denied coverage that the decision was based on peer review as being experimental or investigational as opposed to evidence-based medicine.
Registered Nurse Internal Medicine Office
Aug 2001－Jul 2002
Diagnostic Medical Associates Of North Texas
Full time personal office RN for Dr. Catheryne Zavodny. Assisted with the startup of her new practice. Greeted patients, obtained vital signs, assisted MD during examinations, conducted EKG tests, drew blood for lab work, answered and returned incoming patient inquiries, provided explanations of lab results with Dr. Zavodny's recommendations. Obtained precertifications of medical procedures including: MRI's, CT scans, ultrasounds, echocardiograms, nuclear stress tests, IVP's, and sleep studies.
CCU Registered Nurse
Aug 1999－Jul 2001
Medical City Hospital at Dallas
Successfully completed CCU internship program. Became full time CCU staff RN from 7pm to 7am. Provided primary critical care for patients with acute and complex cardiac, endocrine, renal, neurological, and pulmonary illnesses.
Certified Rehabilitation Nurse
Jan 1998－Aug 1999
Baylor Institute for Rehabilitation
Full time staff CRRN 7am to 3pm provided primary patient care to patients suffering from physical functional loss due to spinal cord injury, CVA, COPD, TBI, MI, MS, Diabetes, Amputations, Joint Replacements, and Complications of Aging. Served as patient advocate, counselor, and teacher for those patients and their families as they faced not only functional loss but also extreme psychological adjustments when faced with severe, debilitating injury or illness.
Certified Rehabilitation Registered Nurse
Feb 1994－Jan 1998
Plano Rehabilitation Hospital
Full time staff RN on 3pm to 11pm shift and unit supervisor as needed. Served as primary caregiver and patient advocate to patients and their family members faced with chronic illness and disability. Involved with many complex wound care cases and chosen by primary wound care specialist to be assigned to his patients exclusively.
Worker's Compensation Registered Nurse Case Manager
Oct 1993－Feb 1994
Allegiance Medical Case Management
Provided comprehensive and cost-effective management of unresolved worker's compensation cases to facilitate coordination of medical care and the return to work process. Field nursing position that involved meeting with the injured employee in person, attending their MD appointments to determine impairment ratings, and meeting with their employer to discuss modified duty options.