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Work Background
Anthem, Inc.Manager
Jul. 2018Covington, Texas, United StatesResponsible for management oversight of departmental units in several states to investigate, resolve, and respond to client/provider appeals and ensure compliance with regulatory requirements. Primary duties may include but are not limited to: Maintains and coordinates staff activities to achieve departmental and corporate goals to improve service to customers/providers and assures regulatory compliance. Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines. Addresses both internal/external customer/provider needs, and concerns related to team activities. Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards. Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Anthem, Inc.Nurse
Sep. 2013 - Jul. 2018Covington, Texas, United StatesEnsures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, and community resources. Responsible for reviewing, processing, and reporting all Medical Director decision appeals including the assessment of medical records or clinical information and applying approved criteria to ensure appropriate processing and that all regulatory, state, and contractual requirements are met. Ensure that the documentation and systems are updated to reflect the medical decisions. Collaborate and assist the Medical Director, Members and Providers with the proper appeals policies.
Weatherford Regional Medical CenterCase Management Nurse
Mar. 2011 - Sep. 2013Covington, Texas, United StatesResponsible for the oversight and management of the utilization management plan for the organization. Major responsibilities consist of coordinating the care of patients across the continuum of illness; promote effective utilization; monitor health care resources; and assume a leadership role with the interdisciplinary team to achieve optimal outcomes. Practices under minimal supervision and performs essential activities of case management, including, evaluation of the appropriateness of setting, assessment, planning, implementation, coordination, and monitoring.
Weatherford Regional Medical CenterRegistered Nurse
Oct. 2008 - Mar. 2011Covington, Texas, United StatesWas responsible for planning, supervising, and evaluating the nursing care of essential functions of patients and for correlating the nursing process, the medical plan of care, and policies. Under general supervision, rendered professional nursing care of patients of all ages through the use of the Nursing process and the promotion, maintenance, and teaching of health. Supervised the provision of nursing care rendered to patients by RN'' LPN'' ORT'' and CST'' and ancillary personnel, assigning and reviewing work. Provided instruction on various techniques. Assisted nurse manager in areas delegated. Provided peri-operative care to all age groups. Assisted in departmental budgets and staffing. Established an effective day to day operational schedule with the OR, PACU, CS, and Anesthesia staff to provide efficient flow and completion of surgery schedule. Represented the department in all aspects of customer service.
West Jefferson Medical CenterRegistered Nurse
Jul. 2002 - Apr. 2008Covington, Texas, United StatesResponsible for patient care in multiple departments, where needed. Including, Med/surg, Telemetry, Post-Partum, Orthopedics, Day surgery, Oncology, SNF, Rehab, ER Short stay and Endoscopy.
Elevance HealthAppeal nurse manager
Covington, Texas, United States
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