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The Reny Company - Workers Compensation Case Manager Resume Example

Luke Young
XXXX XXXXXXXXX XXXXX
Plano, TX 75023
Ph: XXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXX
Professional Summary
Conscientious and accomplished nursing professional qualified by a Bachelor of Science Degree in Nursing with RN licensure since September 1993 and Certified Case Manager since May 2012.  Both in good standing.  Demonstrates independent, resourceful, and efficient self management skills with unsurpassed customer service skills.
Skills
  • Experience with ODG, InterQual, and Milliman
  • Judgment and Decision Making
  • Complex Problem Solving
  • Critical Thinking
  • Customer and Personal Service
  • Active Learning
  • Time Management
  • Coordination
  • Monitoring
  • Computer applications
Experience
Worker's Compensation Case Manager Mar 2014Aug 2014 The Reny Company Plano, TX

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 2013Jan 2014 Ranstad Healthcare Woburn, MA 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 2012May 2013 HealthSmart Irving, TX 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 2011Oct 2012 Inventiv Medical Management Augusta, GA 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 2010Apr 2011 AmerisourceBergen Frisco, TX 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 2007Jun 2009 Health Dialog Incorporated Richardson, TX 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 2002Jul 2005 United Health Group Plano, TX 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 2001Jul 2002 Diagnostic Medical Associates Of North Texas Plano, TX 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 1999Jul 2001 Medical City Hospital at Dallas Dallas, TX 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 1998Aug 1999 Baylor Institute for Rehabilitation Dallas, TX 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 1994Jan 1998 Plano Rehabilitation Hospital Plano, TX 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 1993Feb 1994 Allegiance Medical Case Management Plano, TX 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.
Education
Bachelor of Science: Nursing May 1993 Texas Woman's University Denton, TX
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Resume Details

This is a real resume for a Workers Compensation Case Manager in Plano, Texas with experience working for such companies as The Reny Company, Ranstad Healthcare, Healthsmart. This is one of the hundreds of Workers Compensation Case Manager resumes available on our site for free. Use these resumes as templates to get help creating the best Workers Compensation Case Manager resume.

Previous Companies:

  • The Reny Company
  • Ranstad Healthcare
  • HealthSmart

Previous Job Positions:

  • Workers Compensation Case Manager
  • Utilization Review Nurse
  • Telephonic Case Manager
  • Disease Management Registered Nurse
  • Telephonic Nurse Educator

Schools:

  • Texas Woman's University

Level of Education:

  • Bachelor of Science

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