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ALETA RESUME.FDANurseConsulatant.102015

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Aleta Harris

Aleta R. Harris is applying for a position as a Nurse Consultant with the Food and Drug Administration. She has over 18 years of experience as a Registered Nurse and 15 years of experience as a Nurse Consultant in case management and education roles. Her experience includes work as a case manager, utilization manager, and team leader with various healthcare organizations. She believes her qualifications in areas like Medicare regulations, case management, and quality improvement would make her well-suited for the Nurse Consultant position.

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Aleta R. Harris MSA, BSN, RN, CPHM  240-535-5765  Counterclockwise56@gmail.com  8140 Tamar Drive  Columbia, Maryland 21045 Dear Human Resources Manager: I would like to express my sincere interest in being considered for the position of Nurse Consultant. I strongly believe that my experience and qualifications would be great assets; satisfying the mission and goals of the Food and Drug Administration. Enclosed is a copy of my resume for your review and consideration. Of probable interest to you, is the fact that I possess vast knowledge and experience as a nurse consultant. My career in nursing has provided me with exposure to various aspects of healthcare, fostering astuteness in the application of quality healthcare principles, teaching methodologies, efficiency and profitability within the health insurance arena. Currently, I am employed as a Registered Nurse (RN) Case Manager with Johns Hopkins Healthcare (JHHC) in Glen Burnie, Maryland. Through my experience, I provide ongoing consultative nursing services and coordination of care for a special needs population of Medicaid enrolled members throughout the eastern region; along with a reviewing and planning services for certain government members within, the contracted federal plan through (JHHC). Further, my experience as a Utilization Manager, Case Manager and Team Leader has afforded me the opportunity to become well versed with interpreting and applying federal regulations, health insurance, and Health Management Guidelines, affecting healthcare access, reimbursement and quality outcomes. The following are additional highlights of my healthcare experience and qualifications: • More than 18 years of experience as a Registered Nurse • Approximately 15 years as a Nurse Consultant through case management and education roles • Completion of a Master’s Degree in Health Services Administration (May 2004) • Medicare Advantage Plan Knowledge- Denials (NOMNC Letters) and Medicare Stars • MCO Medicaid Plan knowledge – Value Based Purchasing • Medicare RAC Appeals ( QIO and ALJ levels) • Strong resource with the credentialing process of Delmarva and NCQA accreditation standards • Leadership ability as both an administrative manager and a clinical team leader • Case Management and Utilization Review experience • Extensive training with Milliman and InterQual guidelines • CPHM certification (CPUM and CPUR are now combined) • Strong knowledge of writing and implementing Quality Management Policies and Procedures • Project Management with Executive Senior Management and Department Heads • Facilitating and attending corporate and departmental committees meetings • HEDIS training and experience I am a self-motivated individual; possessing strong interpersonal skills with the ability to readily adapt to the most challenging situations. Please evaluate my strengths and expertise, as I would appreciate further discussion on how I might contribute to seamless quality as a Nurse Consultant with the Food and Drug Administration. Sincerely,
Aleta R. Harris RN, BSN, MSA, CPHM Aleta R. Harris MSA, BSN, RN, CPHM  240-535-5765  Counterclockwise56@gmail.com  8140 Tamar Drive  Columbia, Maryland 21045  NURSE CONSULTANT  Highly accomplished, Hardworking, self-motivated, proactive, and patient-driven professional nurse with astute, comprehensive knowledge of Federal Regulations, Medicare guidelines, Insurance Regulations, education, and nursing processes. Proven ability to provide critical thinking skills essential for providing competent and dignified patient care. Positive interpersonal skills with a servant leader attitude; interface effectively with patients, families, and colleagues. Flexible and adapt easily to changing environment and work schedule. Recognized for professionalism, commitment to excellence, and ability to effectively cultivate meaningful relationships. Hold national certification in Utilization Review Nursing and Nursing Case Management. Experienced with hospice care, home health, inpatient, OBGYN, patient education, reimbursement, insurance authorizations, denial management and leadership. CORE COMPETENCIES Comprehensive Assessments Insurance Regulations Quality Improvement Policy Analysis Admission and Discharge CMS Guidelines Appeals / Denials Management Relationship Cultivation Patient-Centered Care Microsoft Office Programs Computerized Documentation Clinical Care Analysis Medical Record Maintenance Leadership Data Collection AREAS OF EXPERTISE  Interpersonally adept; readily establishing rapport and sense of trust with diverse clients of various ages, cultures, and socio-economic backgrounds, as well as with peers, physicians and support personnel.  Comfortable in fast-paced situations and adept in managing time, prioritizing tasks, and exercising the sound judgment required to improve the quality of patient care.  Proficient in medical terminology, medical processes and use of medical equipment. As member of the medical team, strive to provide continuum of best possible care, keeping needs of patients foremost in mind.  Noteworthy computer and administrative skills. Flexible to changing priorities. Able to quickly identify and resolve problems using available resources. PROFESSIONAL EXPERIENCE Johns Hopkins Healthcare, LLC Glen Burnie, Maryland Case Manager RN (floater) October 2014 to Current Coordinate care delivery and complete member healthcare needs assessments, based on physical and psychological factors; conducting retrospective insurance and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum. Analyze, Interpret and apply Centers for Medicare laws and guidelines for admission and observation stays; ensuring adequate documentation for payment of services. Remain abreast of new laws affecting Medicare and reimbursement by researching legislation and policy updates. Cultivate new relationships with internal and external customers; employing effective communication and collaborative efforts with community-based organizations, while providing consultation for identifying services best aligned with members’ needs. Efforts support local and corporate goals for membership growth. Identify potential medical service delays by educating hospital staff and assisting them with identifying appropriate utilization services. Remain abreast of new laws affecting Medicare and reimbursement by researching legislation and policy updates. Analyze, Interpret and apply Centers for Medicare guidelines for admission and observation stays; ensuring adequate documentation for payment of services. Effectively interface with nursing leadership, team leader and physician for communicating delivery of case management services, services pending, case approvals and denials outlined in company policy. Track and trend data, providing reports necessary for identifying and improving quality issues related to authorizations and denials management. Provide support to the Appeals Management Practice; reviewing medical records and preparing professional, effective clinical appeals in response to medical necessity denials managed care and DRG reassignments, governmental and Recovery Audit Contractors (RAC) denials for hospital clients. Successful appeals have consistently resulted in overturning denied claims and recovering revenue for our clients. Collaborate with nursing leadership and colleagues when leading activities for scheduling and facilitating team meetings, setting agendas, managing and disseminating
information, establishing project timelines; delegating team assignments; adhering to deadlines and providing regular reports and project updates to upper management. United HealthCare XLHealth/Care Improvement Plus Baltimore, Maryland Utilization Management Coordinator September2013-Current Provided nurse consultative services through education and coordination of utilization operations assigned within the Medicare plan and Medicare management team, while implanting intergovernmental Federal regulatory policies. Collaborated with insurance contract specialists for ensuring compliance through applying guidelines for various Medicare products within the Medicare Advantage plan operations. Interpreted and applied policies for ensuring program success. Communicated any changes in patient Model of Care to the Medicare management, and plan interdisciplinary team Coordinated implementation of interdepartmental processes (policies and procedures) related to Medicare business Completed Transfer of Care Risk Assessment for Medicare Advantage Plan members and collection of Medicare Revenue. Participated in medical cost discussions and evaluate the Member Discharge plan to decrease costs. Reviewed the individual Medicare programs to improve and manage benefit delivery Interprets Centers for Medicare and Medicaid Services (CMS) regulations for Skilled nursing (SNF) and Long-term Care facilities (LTAC) with member placement. Prepared denial letters and NOMNC letters for the plan. Mercy Medical Baltimore, Maryland Case Manager RN (floater) May 2013- October 2013 (Temp Employee-Contract) Coordinated delivery and member health care needs through conducting comprehensive nursing assessments, based on physical and psychological factors. Conducted retrospective and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum; improving collaborative relationships with community-based organizations, while providing direction in identifying those that best meet the needs of members and support local and corporate goals for membership growth; and identifying potential medical service delays by helping hospital staff to identify appropriate services utilization. Provided support to the Appeals Management Practice; reviewing medical records and preparing clinical appeals in response to medical necessity denials and DRG reassignments. Successful in overturning denied claims and recovering revenue for our clients by writing professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients. National Institutes of Health Bethesda, Maryland RN-Clinical Research Nurse II September 2012-May 2013 Worked in the Clinical Monitoring Research Program (CMRP), and was responsible for providing clinical research and nursing support to the National Institutes of Health’s (NIH) Division of Research Development with the NIH Clinical Center; specifically supporting the Interventional Radiology Research Program. Supported the research team in providing therapies that use imaging technology to diagnose and treat localized cancers in ways that are precisely targeted and minimally or non-invasive. Collected and analyzed patient data, provided assistance and managed patients through use of program databases. Applied knowledge and training of protocol-specific regulations and functioning according to the provisions of approved investigational protocols. Performed a wide range of duties associated with a protocol’s life cycle from development through termination, with particular attention to writing manuscripts and protocols. Ensured scientific quality and human subject’s protection, Recognizes and supports the needs of data integrity and retrieval, and interprets needs appropriately for principal investigators, patients and other staff members. This position is located in Bethesda, Maryland. Facilitate and coordinates care for patients who have volunteered in the clinical trials protocols within the National Institute of allergy and Infectious Disease division.
Amerigroup Community Care Hanover, Maryland RN- Quality Coordinator October 2011-September2012 Designed and implemented quality improvement studies, including selecting valid and reliable indicators for monitoring and evaluating activities. Created and maintained ongoing quality database system; facilitating and attending corporate and departmental committee meetings and workgroups. Assisted with the planning and execution of health promotions outreach team, for which yearly initiatives to meet annual goals for Medicare Stars and Value-based purchasing (Medicaid) HEDIS measures were established. Analyzed, tracked, and trended data; preparing concise, accurate and meaningful quality management reports in accordance with Company procedures for improving quality. Actively participated in intradepartmental quality management improvement teams; coordinating resolution of high level complaints; educating AMERIGROUP associates about the QM process; Assisting in defining opportunities for improvement through analysis of trends; assisting with preparations for the Quality Improvement Council and other QM related Corporate and Maryland Plan committee meetings; implementing, analyzing and evaluating the Company-wide inter-rater reliability program; assisting various departments with preparation for NCQA and Delmarva Accreditation; maintaining quality management documents, case files and correspondence in an organized, confidential and secure manner; conducting, as appropriate, oversight audits for all nationally delegated vendors; developing and maintaining vendor audit tools; communicating significant findings, including potential risk management issues to the AVP of Quality Management; assisting with coordinating HEDIS Improvement Activities; assisting with coordinating Member and provider Satisfaction Improvement activities; assisting with Health promotions/outreach clinic days; creating the quality management yearly work plan and the end of the year program evaluation for Medicare; and presenting quarterly and semiannual quality reports along with NCQA required analysis to corporate executives and department heads within various committees. Mercy Medical Center Baltimore, Maryland RN Case Manager December 2005-July 2009 Utilized the nursing process for assessing, implementing, and communicating care plan objectives for individual patients to Mercy Hospital’s executive administrative team, while coordinating the identification high-risk patient cases and collaborating regularly with physicians to assure patient access to quality, cost effective health care. Interacted with other nursing staff. Special Recognition: Was recognized for distinguished service by the Medical Director and tapped for participation on the Maternal Child health Care Committee, an interdisciplinary group of doctors, social workers, and nurses tasked to develop health education initiatives that supported state regulatory objectives and requirements. Collected data and initiated QPM, graph data. Assisted with implementation of GE system that would allow for more finite and quicker data collection. Committee responsibilities included: contributing to the establishment of short and long term goals for communicating care plan objectives to patients and their families in addition to identifying barriers to obtaining insurance authorization for admission and continued stay from private insurance agencies, as well as, agencies like Medicare and Medicaid. CareFirst Blue Cross Blue Shield Washington, DC RN -Clinical Care Coordinator August 2003-December 2005 Coordinated services for CareFirst Blue Cross Blue Shield, Hospital based healthcare plan; ensuring service delivery and member health care needs assessments, based on physical and psychological factors; pre-certs; conducting retrospective and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum; improving collaborative relationships with community-based organizations, while providing direction in identifying those that best meet the needs of members and support local and corporate goals for membership growth. Minimized hospitals costs by identifying potential medical service delays that might have resulted in denials. Assisted hospital staff with identifying appropriate patient resources for accessing appropriate levels of care for patients. Interpreted and applied contractual guidelines for companies seeking insurance prior authorizations with active policy modification and analysis.
Mid-Atlantic Medical Services, Inc. (Mamsi) Rockville, Maryland RN- Utilization Review Nurse November 2001-August 2003 Conducted comprehensive utilization review assessments of inpatient cases against Mid-Atlantic Medical Services’ benefit system and provided cost benefit analysis for member care criteria. Facilitated cost containment and provided evaluation on members’ treatment based on medical, mental health, and substance abuse service cost constructs. Provided concurrent and retrospective care reviews to ensure the proper utilization of resources across the care continuum, while proactively collaborating with hospital staff to identify appropriate services utilization. Healthcare Strategies, Inc. Columbia, Maryland RN- Education Counselor and Care Coordinator May 2000-November 2001 Provided consultation and medical reviews for more than 200 insurance companies in maternity, medical- surgical-oncology and psychiatric nursing, drawing from extensive experience as a registered nurse; conducting maternity screening interviews and providing insured clients with medical advice and referrals via a nursing hotline; identifying physical and psychological characteristics of the symptoms and illnesses described by patients; and accurately preparing recommendations and referrals in order to get approval for outpatient/ inpatient surgeries and hospital stays. Assessed patient learning needs, providing education and guidance to patients and staff for outlining clinical outcomes for improving healthcare. McGuire Veterans Affairs Medical Center Richmond, Virginia RN-Charge Nurse/Team Leader September 1998-May 2000 Provided leadership, supervision, and oversight of clinical practice of nursing staff on a 40 bed, medical- surgical-oncology unit. Effectively utilized staffing and overtime resources; assigning nursing hours based on knowledge, skill, ability and patient acuity. Conducted quality chart reviews, ensuring presence of adequate and accurate clinical documentation. Utilized the nursing process; assessing patient care needs, administering pharmacological intervention, and revising nursing policies affecting care and outcomes. Conceived and implemented hospital-wide, quality improvement initiative, “Identifying Best Practices” (for the treatment of high-risk patients); directing the unit’s patient education program, while serving as the primary liaison for cross- functional engagement between the medical- oncology unit and other units within the medical center. EDUCATION Master of Science: Health Administration  Central Michigan University  Mount Pleasant, Michigan May 2004d Bachelor of Science: Nursing  North Carolina Agricultural and Technical State University  Greensboro, NC May 1997 TRAININGS ICD-9 & ICD-10; CPT CODES Interqual Criteria 2014 & 2015 Milliman Care Guidelines LICENSES AND CERTIFICATIONS Registered Nurse-- State of Maryland Basic Life Support (BLS) for Health Providers CPHM Certified (CPUM and CPUR combined) VOLUNTEER AFFILIATIONS Delta Sigma Theta Sorority, Incorporated Chapel of Restoration Food Bank AFFILIATIONS Chi Eta Phi, Nursing Sorority, Inc. Delta Sigma Theta Sorority, Inc., Member (Community Service Committee and Health Outreach Committee) American Association of Managed Care Nurses, Member References Available Upon Request
ALETA RESUME.FDANurseConsulatant.102015
ALETA RESUME.FDANurseConsulatant.102015

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ALETA RESUME.FDANurseConsulatant.102015

  • 1. Aleta R. Harris MSA, BSN, RN, CPHM  240-535-5765  Counterclockwise56@gmail.com  8140 Tamar Drive  Columbia, Maryland 21045 Dear Human Resources Manager: I would like to express my sincere interest in being considered for the position of Nurse Consultant. I strongly believe that my experience and qualifications would be great assets; satisfying the mission and goals of the Food and Drug Administration. Enclosed is a copy of my resume for your review and consideration. Of probable interest to you, is the fact that I possess vast knowledge and experience as a nurse consultant. My career in nursing has provided me with exposure to various aspects of healthcare, fostering astuteness in the application of quality healthcare principles, teaching methodologies, efficiency and profitability within the health insurance arena. Currently, I am employed as a Registered Nurse (RN) Case Manager with Johns Hopkins Healthcare (JHHC) in Glen Burnie, Maryland. Through my experience, I provide ongoing consultative nursing services and coordination of care for a special needs population of Medicaid enrolled members throughout the eastern region; along with a reviewing and planning services for certain government members within, the contracted federal plan through (JHHC). Further, my experience as a Utilization Manager, Case Manager and Team Leader has afforded me the opportunity to become well versed with interpreting and applying federal regulations, health insurance, and Health Management Guidelines, affecting healthcare access, reimbursement and quality outcomes. The following are additional highlights of my healthcare experience and qualifications: • More than 18 years of experience as a Registered Nurse • Approximately 15 years as a Nurse Consultant through case management and education roles • Completion of a Master’s Degree in Health Services Administration (May 2004) • Medicare Advantage Plan Knowledge- Denials (NOMNC Letters) and Medicare Stars • MCO Medicaid Plan knowledge – Value Based Purchasing • Medicare RAC Appeals ( QIO and ALJ levels) • Strong resource with the credentialing process of Delmarva and NCQA accreditation standards • Leadership ability as both an administrative manager and a clinical team leader • Case Management and Utilization Review experience • Extensive training with Milliman and InterQual guidelines • CPHM certification (CPUM and CPUR are now combined) • Strong knowledge of writing and implementing Quality Management Policies and Procedures • Project Management with Executive Senior Management and Department Heads • Facilitating and attending corporate and departmental committees meetings • HEDIS training and experience I am a self-motivated individual; possessing strong interpersonal skills with the ability to readily adapt to the most challenging situations. Please evaluate my strengths and expertise, as I would appreciate further discussion on how I might contribute to seamless quality as a Nurse Consultant with the Food and Drug Administration. Sincerely,
  • 2. Aleta R. Harris RN, BSN, MSA, CPHM Aleta R. Harris MSA, BSN, RN, CPHM  240-535-5765  Counterclockwise56@gmail.com  8140 Tamar Drive  Columbia, Maryland 21045  NURSE CONSULTANT  Highly accomplished, Hardworking, self-motivated, proactive, and patient-driven professional nurse with astute, comprehensive knowledge of Federal Regulations, Medicare guidelines, Insurance Regulations, education, and nursing processes. Proven ability to provide critical thinking skills essential for providing competent and dignified patient care. Positive interpersonal skills with a servant leader attitude; interface effectively with patients, families, and colleagues. Flexible and adapt easily to changing environment and work schedule. Recognized for professionalism, commitment to excellence, and ability to effectively cultivate meaningful relationships. Hold national certification in Utilization Review Nursing and Nursing Case Management. Experienced with hospice care, home health, inpatient, OBGYN, patient education, reimbursement, insurance authorizations, denial management and leadership. CORE COMPETENCIES Comprehensive Assessments Insurance Regulations Quality Improvement Policy Analysis Admission and Discharge CMS Guidelines Appeals / Denials Management Relationship Cultivation Patient-Centered Care Microsoft Office Programs Computerized Documentation Clinical Care Analysis Medical Record Maintenance Leadership Data Collection AREAS OF EXPERTISE  Interpersonally adept; readily establishing rapport and sense of trust with diverse clients of various ages, cultures, and socio-economic backgrounds, as well as with peers, physicians and support personnel.  Comfortable in fast-paced situations and adept in managing time, prioritizing tasks, and exercising the sound judgment required to improve the quality of patient care.  Proficient in medical terminology, medical processes and use of medical equipment. As member of the medical team, strive to provide continuum of best possible care, keeping needs of patients foremost in mind.  Noteworthy computer and administrative skills. Flexible to changing priorities. Able to quickly identify and resolve problems using available resources. PROFESSIONAL EXPERIENCE Johns Hopkins Healthcare, LLC Glen Burnie, Maryland Case Manager RN (floater) October 2014 to Current Coordinate care delivery and complete member healthcare needs assessments, based on physical and psychological factors; conducting retrospective insurance and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum. Analyze, Interpret and apply Centers for Medicare laws and guidelines for admission and observation stays; ensuring adequate documentation for payment of services. Remain abreast of new laws affecting Medicare and reimbursement by researching legislation and policy updates. Cultivate new relationships with internal and external customers; employing effective communication and collaborative efforts with community-based organizations, while providing consultation for identifying services best aligned with members’ needs. Efforts support local and corporate goals for membership growth. Identify potential medical service delays by educating hospital staff and assisting them with identifying appropriate utilization services. Remain abreast of new laws affecting Medicare and reimbursement by researching legislation and policy updates. Analyze, Interpret and apply Centers for Medicare guidelines for admission and observation stays; ensuring adequate documentation for payment of services. Effectively interface with nursing leadership, team leader and physician for communicating delivery of case management services, services pending, case approvals and denials outlined in company policy. Track and trend data, providing reports necessary for identifying and improving quality issues related to authorizations and denials management. Provide support to the Appeals Management Practice; reviewing medical records and preparing professional, effective clinical appeals in response to medical necessity denials managed care and DRG reassignments, governmental and Recovery Audit Contractors (RAC) denials for hospital clients. Successful appeals have consistently resulted in overturning denied claims and recovering revenue for our clients. Collaborate with nursing leadership and colleagues when leading activities for scheduling and facilitating team meetings, setting agendas, managing and disseminating
  • 3. information, establishing project timelines; delegating team assignments; adhering to deadlines and providing regular reports and project updates to upper management. United HealthCare XLHealth/Care Improvement Plus Baltimore, Maryland Utilization Management Coordinator September2013-Current Provided nurse consultative services through education and coordination of utilization operations assigned within the Medicare plan and Medicare management team, while implanting intergovernmental Federal regulatory policies. Collaborated with insurance contract specialists for ensuring compliance through applying guidelines for various Medicare products within the Medicare Advantage plan operations. Interpreted and applied policies for ensuring program success. Communicated any changes in patient Model of Care to the Medicare management, and plan interdisciplinary team Coordinated implementation of interdepartmental processes (policies and procedures) related to Medicare business Completed Transfer of Care Risk Assessment for Medicare Advantage Plan members and collection of Medicare Revenue. Participated in medical cost discussions and evaluate the Member Discharge plan to decrease costs. Reviewed the individual Medicare programs to improve and manage benefit delivery Interprets Centers for Medicare and Medicaid Services (CMS) regulations for Skilled nursing (SNF) and Long-term Care facilities (LTAC) with member placement. Prepared denial letters and NOMNC letters for the plan. Mercy Medical Baltimore, Maryland Case Manager RN (floater) May 2013- October 2013 (Temp Employee-Contract) Coordinated delivery and member health care needs through conducting comprehensive nursing assessments, based on physical and psychological factors. Conducted retrospective and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum; improving collaborative relationships with community-based organizations, while providing direction in identifying those that best meet the needs of members and support local and corporate goals for membership growth; and identifying potential medical service delays by helping hospital staff to identify appropriate services utilization. Provided support to the Appeals Management Practice; reviewing medical records and preparing clinical appeals in response to medical necessity denials and DRG reassignments. Successful in overturning denied claims and recovering revenue for our clients by writing professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients. National Institutes of Health Bethesda, Maryland RN-Clinical Research Nurse II September 2012-May 2013 Worked in the Clinical Monitoring Research Program (CMRP), and was responsible for providing clinical research and nursing support to the National Institutes of Health’s (NIH) Division of Research Development with the NIH Clinical Center; specifically supporting the Interventional Radiology Research Program. Supported the research team in providing therapies that use imaging technology to diagnose and treat localized cancers in ways that are precisely targeted and minimally or non-invasive. Collected and analyzed patient data, provided assistance and managed patients through use of program databases. Applied knowledge and training of protocol-specific regulations and functioning according to the provisions of approved investigational protocols. Performed a wide range of duties associated with a protocol’s life cycle from development through termination, with particular attention to writing manuscripts and protocols. Ensured scientific quality and human subject’s protection, Recognizes and supports the needs of data integrity and retrieval, and interprets needs appropriately for principal investigators, patients and other staff members. This position is located in Bethesda, Maryland. Facilitate and coordinates care for patients who have volunteered in the clinical trials protocols within the National Institute of allergy and Infectious Disease division.
  • 4. Amerigroup Community Care Hanover, Maryland RN- Quality Coordinator October 2011-September2012 Designed and implemented quality improvement studies, including selecting valid and reliable indicators for monitoring and evaluating activities. Created and maintained ongoing quality database system; facilitating and attending corporate and departmental committee meetings and workgroups. Assisted with the planning and execution of health promotions outreach team, for which yearly initiatives to meet annual goals for Medicare Stars and Value-based purchasing (Medicaid) HEDIS measures were established. Analyzed, tracked, and trended data; preparing concise, accurate and meaningful quality management reports in accordance with Company procedures for improving quality. Actively participated in intradepartmental quality management improvement teams; coordinating resolution of high level complaints; educating AMERIGROUP associates about the QM process; Assisting in defining opportunities for improvement through analysis of trends; assisting with preparations for the Quality Improvement Council and other QM related Corporate and Maryland Plan committee meetings; implementing, analyzing and evaluating the Company-wide inter-rater reliability program; assisting various departments with preparation for NCQA and Delmarva Accreditation; maintaining quality management documents, case files and correspondence in an organized, confidential and secure manner; conducting, as appropriate, oversight audits for all nationally delegated vendors; developing and maintaining vendor audit tools; communicating significant findings, including potential risk management issues to the AVP of Quality Management; assisting with coordinating HEDIS Improvement Activities; assisting with coordinating Member and provider Satisfaction Improvement activities; assisting with Health promotions/outreach clinic days; creating the quality management yearly work plan and the end of the year program evaluation for Medicare; and presenting quarterly and semiannual quality reports along with NCQA required analysis to corporate executives and department heads within various committees. Mercy Medical Center Baltimore, Maryland RN Case Manager December 2005-July 2009 Utilized the nursing process for assessing, implementing, and communicating care plan objectives for individual patients to Mercy Hospital’s executive administrative team, while coordinating the identification high-risk patient cases and collaborating regularly with physicians to assure patient access to quality, cost effective health care. Interacted with other nursing staff. Special Recognition: Was recognized for distinguished service by the Medical Director and tapped for participation on the Maternal Child health Care Committee, an interdisciplinary group of doctors, social workers, and nurses tasked to develop health education initiatives that supported state regulatory objectives and requirements. Collected data and initiated QPM, graph data. Assisted with implementation of GE system that would allow for more finite and quicker data collection. Committee responsibilities included: contributing to the establishment of short and long term goals for communicating care plan objectives to patients and their families in addition to identifying barriers to obtaining insurance authorization for admission and continued stay from private insurance agencies, as well as, agencies like Medicare and Medicaid. CareFirst Blue Cross Blue Shield Washington, DC RN -Clinical Care Coordinator August 2003-December 2005 Coordinated services for CareFirst Blue Cross Blue Shield, Hospital based healthcare plan; ensuring service delivery and member health care needs assessments, based on physical and psychological factors; pre-certs; conducting retrospective and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum; improving collaborative relationships with community-based organizations, while providing direction in identifying those that best meet the needs of members and support local and corporate goals for membership growth. Minimized hospitals costs by identifying potential medical service delays that might have resulted in denials. Assisted hospital staff with identifying appropriate patient resources for accessing appropriate levels of care for patients. Interpreted and applied contractual guidelines for companies seeking insurance prior authorizations with active policy modification and analysis.
  • 5. Mid-Atlantic Medical Services, Inc. (Mamsi) Rockville, Maryland RN- Utilization Review Nurse November 2001-August 2003 Conducted comprehensive utilization review assessments of inpatient cases against Mid-Atlantic Medical Services’ benefit system and provided cost benefit analysis for member care criteria. Facilitated cost containment and provided evaluation on members’ treatment based on medical, mental health, and substance abuse service cost constructs. Provided concurrent and retrospective care reviews to ensure the proper utilization of resources across the care continuum, while proactively collaborating with hospital staff to identify appropriate services utilization. Healthcare Strategies, Inc. Columbia, Maryland RN- Education Counselor and Care Coordinator May 2000-November 2001 Provided consultation and medical reviews for more than 200 insurance companies in maternity, medical- surgical-oncology and psychiatric nursing, drawing from extensive experience as a registered nurse; conducting maternity screening interviews and providing insured clients with medical advice and referrals via a nursing hotline; identifying physical and psychological characteristics of the symptoms and illnesses described by patients; and accurately preparing recommendations and referrals in order to get approval for outpatient/ inpatient surgeries and hospital stays. Assessed patient learning needs, providing education and guidance to patients and staff for outlining clinical outcomes for improving healthcare. McGuire Veterans Affairs Medical Center Richmond, Virginia RN-Charge Nurse/Team Leader September 1998-May 2000 Provided leadership, supervision, and oversight of clinical practice of nursing staff on a 40 bed, medical- surgical-oncology unit. Effectively utilized staffing and overtime resources; assigning nursing hours based on knowledge, skill, ability and patient acuity. Conducted quality chart reviews, ensuring presence of adequate and accurate clinical documentation. Utilized the nursing process; assessing patient care needs, administering pharmacological intervention, and revising nursing policies affecting care and outcomes. Conceived and implemented hospital-wide, quality improvement initiative, “Identifying Best Practices” (for the treatment of high-risk patients); directing the unit’s patient education program, while serving as the primary liaison for cross- functional engagement between the medical- oncology unit and other units within the medical center. EDUCATION Master of Science: Health Administration  Central Michigan University  Mount Pleasant, Michigan May 2004d Bachelor of Science: Nursing  North Carolina Agricultural and Technical State University  Greensboro, NC May 1997 TRAININGS ICD-9 & ICD-10; CPT CODES Interqual Criteria 2014 & 2015 Milliman Care Guidelines LICENSES AND CERTIFICATIONS Registered Nurse-- State of Maryland Basic Life Support (BLS) for Health Providers CPHM Certified (CPUM and CPUR combined) VOLUNTEER AFFILIATIONS Delta Sigma Theta Sorority, Incorporated Chapel of Restoration Food Bank AFFILIATIONS Chi Eta Phi, Nursing Sorority, Inc. Delta Sigma Theta Sorority, Inc., Member (Community Service Committee and Health Outreach Committee) American Association of Managed Care Nurses, Member References Available Upon Request