Utilization Management Prior Authorization Nurse

Lisa Kelly

****@******.*** Work from Home/Remote,, US 504-***-****

PROFESSIONAL SUMMARY

I am an experienced and highly skilled professional seeking an entry level management position. I have 8 years utilization Review experience and over 10 years of management experience. During my career I was the supervisor however there was no manager over me in two of my positions therefore I performed all the duties of a manager. The largest department I have managed had 3 areas with 80 employees and I was in the position for 6 years.

WORK HISTORY

Home Health Field RN Hospice on-call at GUARDIAN HOME HEALTH CARE OF LA INC July 2023 - May 2024 (1 Year)

Responsible for providing nursing service in the clients home. This includes measuring and recording patients vital signs such as height, weight, temperature, blood pressure, pulse, and respiration, prepare and give injections and enemas, monitor I O s, dress wounds, collect blood, urine and stool samples for laboratory testing, perform Accuchecks and PT INR in the clients home, wound-vac placement and reinforcement, IV medication administration via peripheral lines, record food and fluid intake and output, provide education to family members on how to care for their relative and or educate the client on their disease process how to care for themselves and what to expect if the disease progresses. In addition providing information on good health habits. For hospice triage after hour calls.

Respond to death calls.

Pronounce time of death, notify physician, coroner and pharmacy. Contact funeral home of choice, discard medications and provide comfort and education to the family.

Reason for gap Higher studies (attending school)

RN Supervisor Charge Nurse at Jo Ellen Smith Living Center March 2023 - Present (2 Years)

Responsible for the smooth and efficient patient flow within the facility. Delegates assignments Provide supervision for the support staff in accordance with their level of training and the patient s acuity.

Works, in cooperation with medical providers to ensure the quality of patient care. Ensure each unit is staffed with properly trained employees. Provider Relations Supervisor at Aetna Better Health August 2020 - June 2021 (1 Year)

Served as a point of contact for all DHH-related questions or concerns. Functioned as the contact between providers and insurance companies. Managing the onboarding procedures for new providers Develop training material and complete orientation for new providers and new employees in the department. Reviewing provider contracts, claims, and insurance codes to ensure provider setup and payment are achieved.

Ensuring medical sites comply with state insurance regulations by scheduling site visits and inspections.

Answering questions about insurance claims and requirements to ensure all staff and providers meet federal and state guidelines.

Assist with research and resolution of provider complaints grievances. Update policy and procedures to ensure the department meets all federal and state DHH Guidelines.

LPN Home Health Nurse at Vital Link Home Health

September 2019 - March 2020 (0 Year)

Responsible for providing nursing service in the clients home. This includes measuring and recording patients vital signs such as height, weight, temperature, blood pressure, pulse, and respiration, prepare and give injections and enemas, monitor I O s, dress wounds, collect blood, urine and stool samples for laboratory testing, perform Accuchecks and PT INR in the clients home, wound-vac placement and reinforcement, IV medication administration via peripheral lines, record food and fluid intake and output, provide education to family members on how to care for their relative and or educate the client on their disease process how to care for themselves and what to expect if the disease progresses. In addition providing information on good health habits. Utilization Management Prior Authorization Nurse at Aetna Better Health November 2015 - August 2020 (5 Years)

Prior Authorization Nurse II Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward request to the Medical Director with recommendations for other determinations. Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings. Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care. Educate providers on utilization and medical management processes. Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical management systems Interact with providers to educate and direct care to participating network providers. Participate in utilization management committees and work on special projects. Accomplishments I have been given the duty of working on all authorizations that cause claims to pend in the system.

This includes identifying and fixing both data entry and systems-level problems that may cause claims to attach to the incorrect authorization or not attach to the authorization. In addition, I currently write approval letters for all Chisholm members and handle retrospective reviews for outpatient requests.

Home Health Licensed Practical Nurse (LPN) at PSA Healthcare September 2015 - December 2017 (2 Years)

Responsible for providing nursing services to pediatric patients on Ventilators in the clients home.

This includes measuring and recording patients vital signs such as height, weight, temperature, blood pressure, pulse, and respiration, prepare and give injections and enemas, monitor I O s, dress wounds, collect blood, urine and stool samples for laboratory testing, perform Accu-checks and PT INR in the clients home, wound-vac placement and reinforcement, IV medication administration via peripheral and PICC lines, record food and fluid intake and output, provide education to family members on how to care for their relative and or educate the client on their disease process how to care for themselves and what to expect if the disease progresses. In addition providing information on good health habits, assisting with scheduling appointments, monitoring medications ordered and their usage, ensure proper care is provided by nursing aides and complete proper documentation of all nursing services and education performed. MDS CMI Nurse at Uptown Healthcare

March 2015 - August 2015 (0 Year)

As CMI nurse my primary responsibility is monitoring case mix and ensuring all payable services are captured during the snapshot, monitoring production of the 3 MDS Coordinators who report to me, ensuring the compliance, accuracy and reliability of patient charts, making sure patient assessments are completed according to company policy and collection of data for use in capturing payment for nursing services provided during patient care and ensuring compliance with treatment norms and privacy standards per the f-tags. Also responsible for the transmission of the data collected during patient assessment, and submission of records requested by state, federal and third party carriers, such as the Center for Medicare and Medicaid Services and private insurance companies. MDS Coordinator Supervisor at Wynhoven Healthcare Center June 2011 - July 2014 (3 Years)

As the MDS Coordinator Supervisor my primary responsibility is monitoring case mix and ensuring all payable services are captured during the snapshot, monitoring production of the 3 MDS Coordinators who report to me, ensuring the compliance, accuracy and reliability of patient charts, making sure patient assessments are completed according to company policy and collection of data for use in capturing payment for nursing services provided during patient care and ensuring compliance with treatment norms and privacy standards per the f-tags. Also responsible for the transmission of the data collected during patient assessment, and submission of records requested by state, federal and third party carriers, such as the Center for Medicare and Medicaid Services and private insurance companies. Accomplishments January 2012 I was assigned the responsibility of completing all configurations for Point Click Care which is a new paperless electronic record system. This responsibility includes basic configuration of the system, creation of forms and task which allows the CNA s to document using Kiosk and the nurses to pass medication using electronic mars and write progress notes from a tablet attached to the cart or the computer at their nursing stations.

I am also responsible for entering new employees in the system, training all current and new employees on using the electronic record system and updating correcting any configuration problems which may occur.

PRN Licensed Practical Nurse (LPN) at Lafon Nursing Home December 2010 - December 2012 (2 Years)

Responsible for providing basic bedside care which includes measuring and recording patients vital signs such as height, weight, temperature, blood pressure, pulse, and respiration, prepare and give injections and enemas, monitor catheters, dress wounds, collect samples for testing, perform routine laboratory tests, wound-vac placement and reinforcement, IV medication administration via peripheral and PICC lines, record food and fluid intake and output. Licensed Practical Nurse (LPN) at Mullen Immunization Clinic September 2010 - November 2014 (4 Years)

Provide seasonal immunization and health screening at clinics throughout the area. Duties include Accurate patient documentation and consent form completion Health screening Background screening Experience performing finger sticks Knowledge of common health screening equipment Required Immunizations based on patient medical history EDUCATION

Delgado Community College New Orleans -

Graduated 1999-01-01

Associates in Business Administration

Excelsior College -

Graduated 2022-01-01

RN

Nunez Community College -

Graduated 2009-01-01

LPN

SKILLS

Mcg, 8 years

Case management, 8 years

Claims Payment, 15 years

Policy Review, 10 years

Project management, 10 years

Prior Authorization, 8 years

Billing, 25 years

Acute, 10 years

Pediatric, 2 years

Home health, 5 years

Hospice, 2 years

Epic, 2 years

Clinical Quality Management, 8 years

Data entry, 25 years

Coaching And Mentoring, 20 years

CERTIFICATIONS

Cpr

BLS

ABOUT ME

I have a drivers license

I have management experience: 1 years

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