Appeals Nurse - Centene Corporation/Spectraforce - Raleigh, NC 27603
(2025-10 - 2026-05)
- Review and interpret clinical information
- Compose clinical summary for Medical Director review
- Process the appeal appropriately
Case manager, Utilization Review - LA County Firefighters Health and Welfare Plan - El Monte, CA 91731
(2018-09 - 2025-04)
- Apply appropriate criteria and make determination for pre-service and retro reviews
- Process appeals
- Collaborate with members, provider offices, hospitals to establish appropriate care
- Interpret clinical information for LA County Firefighters Health Plan Trust
- Compose letters of denial
Utilization Management Professional - Magellan Complete Care - Miami, FL 33152
(2014-08 - 2018-08)
- Interpret clinical information for Florida Medicaid HMO MCC
- Apply information to InterQual criteria and MCG
- Approve when appropriate
- Summarize for Physician Review when appropriate
- Help customers on phone queue
Utilization Review Pre-Auth Coordinator - Coventry Cares Kentucky - Tampa, FL 33634
(2012-08 - 2014-08)
- Interpret clinical information for Kentucky Medicaid patients
- Apply information to InterQual criteria
- Approve appropriate request under Coventry guidelines and InterQual criteria
- Write summery of clinical information for Medical Director Review if criteria and /or Coventry guidelines not met
Clinical Reimbursement Director - Evergreen Woods Health and Rehabilitation Center - Springhill, FL
(2011-08 - 2012-08)
- Case Manage Medicare, Medicaid, and HMO patients clinical assessment schedule according to Medicare/Medicaid guidelines and patient needs.
- Participate in weekly interdisciplinary clinical meetings and determine nursing skill for patients.
- Meet daily with the Director of Rehab and review change of therapy, start of therapy, and end of therapy for all Medicare and HMO patients.
- Adjust the patient's assessment schedule according to Medicare guidelines with the information obtained at these meetings.
- For all new admissions, I complete all appropriate Care Plans, complete a diagnosis list including ICD 9 codes, and complete entry trackers required by Medicare/Medicaid.
- Ensure assessment completion by deadlines determined by Medicare/Medicaid.
- Participate in an interdisciplinary meeting at month end to match billing rates with assessment rates.
Admission Nurse and Surgery Scheduler - Shriners Hospital for Children - Tampa, FL
(2001-06 - 2011-08)
- Coordinate admission to hospital for pre-op patients and International patients
- Screen for surgical contraindications such as head lice, wounds, and illness
- Consult with multidisciplinary team regarding clearances
- Responsible for determining custody of pediatric patients and obtaining proper documentation
- Coordinate a multidisciplinary surgical team including staff surgeon, outside surgeon, anesthesia, radiology, and ortho tech
- Educate families of process and surgical procedure
Staff Nurse Outpatient Department - Shriners Hospital for Children - Tampa, FL
(1998-03 - 2001-06)
- Triage and coordinate patient visits
- Assess demographics, growth and development, orthopedic, psychosocial, and educational needs of patients and their families
- Assist with employee health program including TB skin test, annual health program, flu shots and occupational health needs
- Manage family concerns regarding patient problems including pain management, health services, calling in prescriptions and coordinating follow up
- Expedite the flow through the outpatient clinic by making sure that patient needs are met in a timely and organized manner
- Communicate to other health team members the various patient needs
Charge Nurse Dialysis Clinic - Gambro Healthcare - Zephyrhills, FL
(1997-08 - 1998-03)
- 11 patient hemodialysis unit
- Evaluated water system for safety prior to dialysis
- Measured and prepared medication for technicians and LPN's
- Administered medications for technicians
- Monitored lab results and changed medications accordingly
- Notified physician of changes in patients condition
- Initiated, monitored, and discontinued dialysis on individual patients and patient groups
Staff Nurse Progressive Care Unit - East Pasco Medical Center - Zephyrhills, FL
(1996-09 - 1997-06)
- Admitted and discharged patients
- Prepared patients for cardiac catheterization
- Monitored patients on telemetry
- Interpreted rhythm strips and implemented changes in care accordingly
- Monitored lab results and implemented changes in care accordingly
- Initiated and maintained critical care IV medication
Staff Nurse Surgical floor - East Pasco Medical Center - Zephyrhills, FL
(1995-06 - 1996-09)
- Educated patients on pre-operative/post-operative information
- Initiated pre-operative preparations such as IV's and medications
- Performed post-op care of patients
- Admitted and discharged patients
