yyyyyy x. yyyyyy

xxx-xxx-xxxx • abc@xyz.com

 

 

 

solutions-focused professional eager to offer 10+ years of cross-functional case management and nursing experience within a broad range of environments toward supporting an ethical employer in maximizing success.

 

profile of qualifications

 

         integral leader offering a solid background working with patients experiencing serious to complex and / or catastrophic injuries and illnesses, including showcasing strong needs analysis and multifaceted treatment talents.

         top performer who achieves healthcare cost savings by decreasing patient reliance on urgent care and emergency room visits and unnecessary diagnostic testing while facilitating rapid progression through treatment protocols.

         ambitious self-starter with a proven history of providing responsible medical case management based on strict industry and / or healthcare facility standards of practice while ensuring high-quality patient services processes.

         excellent communicator and effective advocate who seamlessly interfaces between physicians, patients, and families, including leading details-driven nursing staff (e.g. lpns, cnas) in optimizing organizational efficiency.

 

key areas of expertise

 

case management                                                   process improvement                                                  regulatory compliance

healthcare operations                                           budget planning / control                                           workflow prioritization

physician / patient relations                               policy / procedure development                              team building / leadership

 

professional synopsis

 

rn case manager (outpatient)

 

        utilized broad scope of healthcare knowledge toward triaging referrals from multiple sources and identifying cases with potential to be impacted from case management, along with collaborating between members pcp, ancillary providers, and family caregivers to isolate problems, communicate solutions, and develop short- / long-term goals.

         led cm efforts across a continuum of care to promote quality outcomes and minimize healthcare delivery fragmentation, and created and implemented cost-effective treatment plans incorporating community resources.

        demonstrated clinical knowledge to assess and evaluate requests for authorization, including handling screening, eligibility verifications, benefits interpretation, and issues research to deliver objective decisions per btmg criteria.

        improved case management throughout delivery system and across the care continuum by developing, implementing, and evaluating solutions-focused standards of care, policies, procedures, and medical review criteria.

        liaised among cm members, referral services and q&hi departments, claims staff, and health plan representatives.

 

pre-admissions case manager

 

        strategically steered pre-admission screening reviews of er patients using interqual criteria to determine appropriateness of admission, level of care (e.g. ip, observation, op), and location of services to be provided (e.g. icu, tele, med / surg), along with performing initial utilization review on new admissions to promote efficient workflow.

        expertly facilitated discharge planning services from the er, including coordinating home health services, snfs, hospice services, and transfers to other acute care facilities at the direction of the attending and er physicians.

        interfaced among 3^rd party payer cm for admissions, status determination, or discharge planning barriers.

        reviewed elective scheduled admissions for appropriateness of status.

 

travel nurse ur / concurrent review / case manager

 

        drove healthcare operations efficiency by obtaining necessary information from appropriate facility staff, practitioners, and providers regarding the clinical status, progress, and care being provided to patient members.

        contributed solid nursing abilities toward assessing clinical condition of members and the ongoing provision of medical services and treatments to determine benefits coverage, as well as notifying practitioners and providers of coverage determinations in the appropriate manner and within the appropriate time frame.

        identified continuing care needs early in the inpatient stay to facilitate discharge to the appropriate setting.

toshia huston, rn, bsn, ccm                                            ~ page two ~                                                xxx-xxx-xxxx

 

professional synopsis (continued)

 

health advocate nurse / case manager

 

         identified insurance members with unmet healthcare needs at risk for hospital admission / readmission, including objectively assessing and / or managing readmission risk related to targeted chronic / serious diseases.

         communicated with members and providers to assess quality and appropriateness of care post-hospital discharge.

         collaborated with clinical staff members to enhance quality and efficiency of healthcare delivery processes, along with participating in weekly meetings with medical director to review cases.

 

advice nurse / rn

 

         applied dynamic interpersonal relations talents toward receiving, triaging, and responding to telephone calls from members requiring medical and nursing advice by assessing patient problems and utilizing approved guidelines.

         directed access to care (e.g. emergent care, urgent care, routine, same day appointment, follow ups, self homecare) based on outcomes of nursing assessment, as well as documenting detailed calls according to established standards.

        communicated with physicians and behavior health staff for member calls requiring physicians / bh involvement.

 

rn supervisor (roles held separately)

 

         played a vital role in ensuring seamless healthcare processes by assisting in interpreting facility policies and objectives which was instrumental in planning and prioritizing team workflow to maximize use of nursing resources.

         led top-performing teams of lpns and cnas in delivering high-quality healthcare services to key resident clientele.

         drafted, developed, and disseminated resident assessment and comprehensive care plans as resident conditions changed, and assisted in staffing department labor at level appropriate to resident care needs and facility budget.

         directed all qa monitoring, infection control tracking, and wound assessments, along with interpreting policies and facility goals to ensure all staff understood and promoted the rights of each resident in providing superior care.

 

assistant director of nursing

 

         optimized healthcare success by participating in the implementation of policies and procedures to support nursing department objectives, including developing resident assessment and care planning processes in compliance with resident care needs and regulatory agency requirements, and assisting with all nursing department compliance.

         assisted in operational quality improvement processes and activities, and provided clinical expertise to monitor and review resident incidents to identify possible legal issues and patterns requiring preventative intervention.

 

rn supervisor

 

         supported oversight and evaluation of various resident healthcare needs, ensured rehabilitative procedures were promptly performed as required, liaised among physicians during patient rounds, and supervised lpns and cnas.

         responded to wide-ranging emergency calls on healthcare unit and within entire retirement community, along with demonstrating clinical competence in assisting with nursing processes during resident interventions and care.

 

staff rn (med-surg / ortho-neuro)

 

         provided accurate and empathetic direct care to patients within diverse hospital areas, including administering medications via all routes, inserting and maintaining catheters and iv sites, recognizing changes in patient conditions, maintaining all charts and transcribing physician orders, and consulting among senior nursing teams.

 

education, licensure & certification

 

bachelor of science in nursing                                                                                                                      georgia state university

 

registered nurse (since xxxx)                                                                                           states of georgia, arizona & california

certified case manager (since 2008)                                                                                            commission for case management

 

cpr certified • bls certified