Objective

I am seeking to further apply and expand my education and experience in the medical field and managed care industry, utilizing knowledge and education, extensive computer facility, and experience.

Experience

2001-Present  Oxford Health Plans, Trumbull CT

Telephone Triage Nurse, Nurse Auditor

Primary role in this capacity has been directing callers to the appropriate care in the appropriate setting in the appropriate time frame utilizing proprietary software.  Secondary roles include facilitation of both the case management and the utilization review process.   Outstanding performance ratings have contributed to promotion to top level designation, as well as promotion to nurse auditor position. 

Spectrum Review Services provides contracted utilization review and medical case management services to varied clients, encompassing self-funded ERISA plans, private insurance carriers, non-participating workman's compensation carriers, and Medicare supplements. As utilization review coordinator, I conducted telephonic review with the entire matrix of medical providers to accomplish certification of medical necessity for procedures, medical equipment, home health services, therapies, and inpatient care. A vast and ever increasing familiarity with anatomy, ICD-9/CPT coding, medical/surgical/procedural terminology, pathophysiology, clinical pathways, and surgical indications was key to efficient well-documented determinations. I participated in a successful URAC accreditation process. As medical case manager, I worked telephonically with the complete spectrum of medical providers, patients, and office personnel within occasionally labyrinthine benefit structures, limitations, and exclusions in an effort to coordinate and ensure quality care in the most cost-effective manner. I was intimately involved in the identification and anticipation of needs throughout the care continuum, steerage toward preferred providers, negotiation with out-of-network providers and transplant facilities, monitoring/reporting of medical status, medical necessity evaluations, mediating, procuring documentation necessary for claim evaluation, and assisting with alternative care arrangements. I was certified by the Commission for Case Manager Certification in 12/99. As Director of Utilization Review, in addition to the duties of coordinator, I utilized the Internet for criteria development sources, research related to emerging technology, and evidence based support for proposed care not addressed within standard criteria. I facilitated peer reviews and their appeals for outside clients as well as internal determinations. I monitored for timely compliance of the utilization review process per URAC guidelines. I coordinated the utilization review aspect of a successful and event-free transition to alternative utilization review software.

Education

1991–1996 Houston Community College Houston, TX

Skills

In addition to multi-state nursing licensure, an ability to see beyond the numbers and a facility with all programs in Microsoft Office software, including expertise in Word, Front Page, and Excel combine to  enable excellent performance in the office nursing setting.

Interests

Internet, software, web publishing, biking, hiking, and beaching.