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Telecommute Nurse Reviewer

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Telecommute Nurse Reviewer

This position is remote and can be done from a home based location.​ Must have an home office /​work space.​ Previous telecommuting experience preferred, but not required.​

The position performs Registered Nurse reviews within the various Utilization Management products (medical bill review, claim file review, ICS) on multiple accounts.​  Assists co-workers and clients with clinical questions and proper procedures.​  Handles special projects as required by the clients and carries out other tasks as directed by management.​  Maintains production standards set forth by department manager and objectives.​

http://jobview.monster.com/GetJob.aspx?JobID=90553303&
Work Pays At Home
mernetta@aol.com mernetta@aol.com
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Re: Telecommute Nurse Reviewer

 I'm interested in this job and would like contact with the recruiter.




                                               Victoria Robinson, RN
                                                28128 Berkshire Dr.
                                              Southfield, Michigan 48076
                                                248-357-2577-Home
                                                248-224-7643-cell                                    
           
 RN Case Management /Utilization Review/ Case Manager Worker’s Compensation

       12/2007- Present               Aetna Medicare Insurance
•  Assessment of member’s health status and care coordination needs.
•  Utilization Review of inpatient stays and discharge planning
•  Telephonic Case Management Nurse Consultant (Medicare Unit)

   Review medical records to determine whether the documentation meets criteria for medical
   necessity for inpatient admission.
•  Identify members that may benefit from case management intervention.
•  Develop and implement care plans.
•  Proactive Telephone calls to members' to assess medical status.
•  Identify the gaps and barriers of the member’s Health Assessment.
•  Provide patient education to assist with self-care of the disease process and send appropriate  
   educational information if requested.
• Interact with Medical Directors for assistance with problem cases.
•  Coordinate care for members with referrals to Aetna’s Disease Management, Behavioral Health,
   Social Workers and Outside Vendors if needed.
•  Coordinate services as needed for Home Healthcare, DME, and Specialist with the assist of
   Medical Directors.
•  Educate the members on the Disease Process.
•  Encourage the members to make healthy choices managing their healthcare.
•  Document all the above information and reassess if needed.
•  Use Millman and Robert criteria to evaluate and identify healthcare service needs using clinical
   knowledge to assure member receives care in the most appropriate setting.
• Telephone calls to members in hospital to introduce CM and CM process, and assure member CM
   Nurse will assist them on discharge.
• Complex telephone call to member’s home on discharge to follow up on their care and start an
   assessment to determine gaps and barriers that needs to be address.
• Apply case management concepts to complex issues in using problem solving techniques to
   promote optimum patient outcomes.







5/2007 - 12/2007
                                                          Travelers Insurance                
                 
                          Workers Compensation RN Telephonic Medical Case Manager
                                           (Traveler’s closed and left Michigan)

Telephonic medical case management with emphasis on early intervention, return to work planning, coordination of quality medical care on claims involving disability and medical treatment as well as in-house medical reviews as applicable to claim handling laws and regulations.  Responsible for helping to ensure injured parties receive appropriate treatment directly related to the compensable injury or assist claim handlers in managing medical treatment to an appropriate resolution.

PRIMARY DUTIES:  
• Contact medical provider and injured parties on claims involving medical treatment and or
  disability to coordinate appropriate medical care.
• Develop medical management strategy and give the provider information necessary to facilitate a
  return to work plan on claims requiring disability management.
•CM is responsible for ongoing evaluation of treatments, and return to work plan within established
  protocols.

 Work with medical providers and suggest cost effective treatment alternatives, when appropriate.
•Help ensure that all injured parties are on an aggressive treatment plan.
•Authorize medical treatment and associated diagnostic testing on assigned claims as allowed by
 state policy jurisdictions for nurses handling Workers Compensation Claims.  Perform Utilization
 Review according to established guidelines.
•Utilized physician advisor program.
•Proactively manage the medical expenses by partnering with specialty resources to achieve  
  appropriate claim outcomes (SIU, Legal, Risk Control, Disability Management, IME and Peer Review
  vendors, Major Case, etc.)
• Obtain medical records from providers telephonically during initial contact.
   Follow up with written correspondence if necessary.
• Discuss medical information and disability status with claim handler and integrate into overall
   strategy to ensure appropriateness of indemnity payments.
• Provide technical assistance and act as a resource for claim handling staff.
  Contact employer to initiate modified duty or full return to work.
• Obtain job description and discuss job modifications required to ensure a prompt return  to work.
• Medical Case Manager will work with employer injured party, provider and claim handler to expedite return to work.
• Identify cases requiring task assignments to field case managers, discuss with supervisor for assignment to Medical or Vocational Case Manager, or vendor.
• Document all contacts and outcomes related to case activity in system.
• Necessary   to   facilitate a   return  to work  plan  on claims requiring disability  management.
• Responsible   for ongoing   evaluation   of   treatment   and  return  to work plan, within  established protocols.
• Work with medical providers and suggest cost effective treatment alternatives, when appropriate.
• Help ensure that all injured parties are on an aggressive treatment plan. Authorized  medical  
  treatment and associated diagnostic testing on assigned claims as allowed by state or policy
  jurisdictions.  
• Proactively manage the medical expenses by partnering with specialty resources to achieve
  appropriate claim outcomes (SIU, Claims Adjusters, Disability Management, IME, and Major Case Adjusters.
• Obtain medical records from providers telephonically during initial contact, and follow up with
  written correspondence if necessary.
• Discuss medical information and disability status with claim handler and integrate into up with
  written correspondence if necessary. overall strategy to ensure appropriateness of indemnity payments.
• Provide technical assistance and act as a resource for claim handling staff.Contact employer to initiate modified duty or full return to work.
• Obtain job description and discuss job modifications required to ensure a prompt return to work.
  Medical Case Manager will work with employer, injured party, provider and claim handler to
  expedite return to work.
•Identify cases requiring task assignments to field case managers, discussions with supervisor for assignment to Medical or Vocational Case Manager, or vendor.
• Document all contacts and outcomes related to case activity in system.


2006 - 5/2007                
                                              Karmanos Cancer Center                            
                                             Care Management Specialists

•    Use INTERQUAL guidelines for utilization review of inpatient admissions.
•    Reviewed faxed or Telephonic medical information with INTERQUAL
•    Review medical records to determine whether the documentation meets criteria for medical  
     necessity for inpatient admission.
•   Case management and discharge planning of Homecare, IV infusing, and DME equipment
     according to criteria.
•   CM taught indications for medications and managing illness and disease.
•   Audit charts on discharges to set the hospital fee. Audit charts for retro review.
•   Scheduled appointments for patients to return to the Oncology clinics.
•   Facilitate Case Management Team Meetings with the Oncologists, Physician Assistants, Nurses
    and Therapist.
                                                     
5/2005-2006  
                                                                             MPRO
                                                    UR Telephonic Nurse (Medicaid)
• Performed Telephonic Utilization Review with state guidelines and INTERQUAL criteria for
   inpatient.  Review medical records to determine whether the documentation meets criteria for
  medical necessity for inpatient admission.
• Reviewed   admissions, per DRG and 15 day re-admissions per state guidelines.
• Setup appeals for the physicians by specialty.
• Telephonic Reviews and Retro reviews, with input of information into the Computer System.
• Michigan Peer Review Organization is contracted by the state of Michigan to handle Medicaid
   manage care throughout the state.
• Reviewed charts from Providers for criteria and assisted Medical Directors with appeals.


4/2004 - 5/2005                  
                                                                     CAPE Health Plan
                                       
                                  Telephonic Utilization Review Nurse – State MEDICAID

• Telephonic Utilization Review with INTERQUAL criteria for inpatient admissions per 15 day DRG
  and readmissions according to state guidelines. Review medical records to determine whether the
  documentation meets criteria for medical necessity for inpatient admission.
•Computer input of telephonic reviews and faxes.
• Assisted with discharge planning for transfers to hospitals, skill care facilities and LTAC.
• Reviewed charts for appeals.  Submit findings of criteria met or not met in form of a synopsis and
  send to the medical director for review.       (Company closed.)



4/2003- 9/2004
                                                  Review Works
                                             Medical Review Specialist

(Days worked were dependent upon the number of charts sent to Review Works  by mail from Insurance companies. Receive days off if not enough work)
Review auto insurance claims/charts for information of medical relatedness to injuries.
Code Services and Medical diagnoses according to ICD-9, CPT, and HCPCS.
Re- coded as necessary and sent letters explaining why service codes have been downgraded or upgraded.
• CHART REVIEWS TO DETERMINE THE PAYMENT FOR  CLAIMS USING  STATE SCHEDULE FEE TABLE FOR THE STATE  OF  RESIDENCE FOR  THE  CLAIMANT  .
• Audited 90 charts per month of multiple insurance companies.
• Coded Services, Used Encoder Pro. HCPCS, CPT, ICD-9, NDAS /2004
 
            8-2004        
                                             Healthcare Professionals/Maxim Agency
                                              UR/Case Management/Chart Audits

• Performed Telephonic Utilization Review for hospital admissions and length of stays with Medical
  criteria. Review medical records to determine whether the documentation meets criteria for medical necessity for inpatient admission.
• Used:   INTERQUAL, MPRO, and Millman and Roberts.
•Charts Audits, Case Managed DME equipment, Homecare, and Nursing home placements.
•Assignments with multiple insurance companies: BLUE CROSS/BLUE SHIELDS, HEALTH ALLIANCE
  PLAN, DETROIT MEDICAL CENTER CLINIC PLAN -MEDICAID, GREAT LAKES HEALTH PLAN, MEDICAID.
•Wellness Plan Insurance Company




09/1999-2000
                                                            North Oakland Medical Center
                                         Telephonic Case Manager and Utilization Review Nurse

• Utilization Review of medical records to determine whether the documentation meets criteria for
  medical necessity for inpatient admission.
•Contact insurance companies to give telephonic reviews and criteria for admissions.
  Discharge planning to meet the needs of patients that may need assistance in home.
•Work with Physicians and medical teams in planning patients discharge.
•Coordination of Homecare, Durable Medical Equipment, Nursing Home Placement, and      
  Homecare Nurses, PT/OT/Speech.
 This Hospital has been searching for large medical group to buy it. Has threaten to close

 
              Medical Experience:

• Michigan Health Corp /Michigan Osteopathic Hospitals –   PSYCHIATRIC Nurse and OR NURSE 1987 – 1992 - Closed
• Detroit Receiving Hospital 1982- 1986 then 1987 – 1989 contingent (FULL TIME 4 YEARS TO CONTINGENT 1YEAR)
•Great Lakes Rehab Hospital - Floor Manager  
•Northville State Hospital - Psychiatric Nurse 1986-1987
• INTRACORP:  2000 - RN WORKER COMP CASE MANAGER FOR CHRYSLER CORPORATION
• 3 point contact (member, employer, physicians) requested IME‘s, FCE, and attending physician‘s
  evaluations, assessments and RTW dates, Nurses notes/ PT/OT NOTES AND ASSESSMENTS.
• Cranbrook Nursing Home - Assistant Director of Nursing

   ALPHA MANOR – Director of Nursing
• Arnold Nursing Home - Started as Supervisor and then to Assistant Director of Nursing
  (No longer open, owner’s closed.)
 
 
       Education:
Henry Ford College
Associate of Science in Nursing 1992
Detroit Practical Nursing 1981
 
Licensure: State of Michigan License Registered Nurse





                                                   
Victoria Robinson,RN Victoria Robinson,RN
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Re: Telecommute Nurse Reviewer

Hello, I'm still interested in a Telecommute Urilization Review Job or Telecommute Case Management , I have worked better half of my career doing both in Insurance offices and now I would like to wor from home .
I have taken a job as a Contractor  doing the utilization Review . I'm paid as I work  and  I have set up an office in my home   with a computer , phone with 800 number , privacy with locked door , and locked file
cabinet . Reference books and all, So Iam ready if there is a company ready to hire a Nurse with Case Mangement or Utilization Review experience .
phone number : 888-353-6330 or 248-353-1005- business phone.
Victoria Robinson Victoria Robinson
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Re: Telecommute Nurse Reviewer

In reply to this post by Work Pays At Home
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Victoria Robinson RN Victoria Robinson RN
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Re: Telecommute Nurse Reviewer

In reply to this post by Victoria Robinson,RN
Looking for a telecommute  Nurse reviewer Job , please help!
mernetta@aol.com mernetta@aol.com
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Re: Telecommute Nurse Reviewer

In reply to this post by Work Pays At Home
I requested removal from the board, my resume has ben on it over a year now . I requested today 9/15/2012.
PLEASE delete the information.
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