Victoria Robinson, RN
28128 Berkshire Dr.
Southfield, Michigan 48076
[Send email to request phone number] 57-2577-H
[Send email to request phone number] 24-7643-cell
RN Case Management /Utilization Review/ Case Manager Worker’s Compensation
12/2007 - Present Aetna Medicare Insurance
Telephonic Case Management Nurse Consultant ( Medicare Unit )
Assessment of members health status and care coordination needs.
Review of inpatient and discharge planning.
Identify members that may benefit from case management intervention.
Development and implementing of care plans.
Proactive Telephone calls to members' to assess medical status.
Identify gaps or barriers in the health assessment.
Provide patient education to assist with self care of disease process and send
appropriate 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 members on disease processes .
Encourage members to make healthy choices in managing their healthcare.
Document all the above information and reassess if needed.
Utilize Milliman 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, an
assure member CM Nurse will assist them on discharge.
Complex Telephone call to member’s home on discharge to follow up and start
assessment to determine gaps and barriers. Apply case management concepts to
complex issues in using problem solving techniques to promote optimum patient
outcomes.
Monitor and evaluate the plans involving the Medical Director as indicated.
5/2007 - 12/2007 Travelers Insurance
Workers Compensation
RN Telephonic Medical Case Manager
( Traveler’s closed and left the state.)
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.
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. Authorize medical treatment and associated diagnostic testing on
assigned claims as allowed by state or policy jurisdictions. For nurses handling
Workers Compensation Claims, perform Utilization Review according to established
guidelines. Utilize 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, and
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. Authorize 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 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.
2006 - 5/2007 Karmanos Cancer Center
Care Management Specialists
Utilization Review using INTERQUAL guidelines for inpatient admissions.
Reviews are faxed or Telephonic. Case management and discharge planning for CM
approved 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.
Set up appointments for patients to return to the Oncology clinics.
I had case management team meetings with the Oncologists, Physician Assistants,
Nurses and Therapist.
MPRO
UR Telephonic Nurse (Medicaid)
5/2005-2006 Performed Telephonic Utilization Review with state guidelines and
INTERQUAL criteria for inpatient.
Admissions, per DRG and 15 day re-admissions per state guidelines.
Setup appeals for the physicians by specialty.
Telephonic Reviews, 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 to assist Medical Directors with
appeals.
9/2004 - 5/2005 CAPE Health Plan
UR Telephonic Nurse - MEDICAID
Telephonic Utilization Review with INTERQUAL criteria for inpatient admissions
per 15 day DRG
and readmissions according to state guidelines.
Computer input of telephonic reviews and faxes.
I assisted with discharge planning for 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. Move out of State)
4/2003- 9/2004 Review Works
Medical Review Specialist
( Days worked dependent on the number of charts sent in by Insurance the
companies, 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
down graded or upgraded.
I DID CHART REVIEWS TO DETERMINE PAYMENT SET BY THE STATE SCHEDULE FEE TABLE.
Audited 90 charts per month for multiple insurance companies.
Coded Services, Used Encoder Pro. HCPCS, CPT, ICD-9, NDAS /2004
1998-Present Healthcare Professionals/Maxim Agency
UR/Case Management/Chart Audits
I performed Telephonic Utilization Review for hospital admissions and length of
stays with Medical criteria.
Use: INTERQUAL, MPRO, Millman and Roberts. Did Charts audits,
Case Manage 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
09/1999-5/2000 North Oakland Medical Center
Telephonic Case Manager/ UR Nurse
Utilization Reviewed on medical charts to obtain approval for inpatient length
of stay per criteria.
Contact insurance companies to give telephonic reviews and criteria for
admissions.
Discharge planning. Work with Physicians and teams in planning patients
discharge.
Coordinate homecare, durable medical equipment, or nursing home placement,
homecare PT/OT/Speech.
Hospital has been searching for large medical group to buy it.
Medical Experience:
Michigan Health Corp /Michigan Osteopathic Hospitals - PSYCHIATRIC Nurse / OR
NURSE 1987 - 1992
Detroit Receiving Hospital 1982- 1987 - 1992 (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
FOR ESIS AND CIGNA . WORKED DIRECTLY IN THE PLANT OFFICES. NEW CONTRACT.
CONTRACT LOST . 3 point contact ( member , employer , physicians ) request
IME‘s, FCE, and attending physician ‘s evaluation and assessment.
Cranbrook Nursing Home - Assistant Director of Nursing
ALPHA MANOR - DON
Arnold Nursing Home - Started as Supervisor and then to Assistant Director of
Nursing - No longer open, owners closed.
Education: Henry Ford College
Associate of Science in Nursing 1992
Detroit Practical Nursing 1981
Licensure: State of Michigan License Registered Nurse
Kaplan University : Taking classes now
Bachelor in Health and Wellness
Grad date : 08/2012
Dear Employer,
I am a Nurse with a lot of experience in Telephonic Case Management.
I have experience in the Hospital, LTAC, and Manage care insurance companies,
Field Case Management and Worker Compensation, and Audit Review Specialist.
I am dedicated to the care of people and making sure they are educated about
their illnesses . Following physicians orders and educating those that need it
on how to take care of their health , and giving explanation as to why this is
important in maintaining healthy lives, provides people with some comfort in
knowing and understanding what to do about their illnesses.
My job as a Nurse is accomplished when patients understand and can give feedback
and are able to be self directed in their care.
Due to my experience as a CM in the hospitals, LTAC, and Inpatient / Outpatient
Case Management in Oncology.
I been have able to reach out to other resources in the communities the member
lives in to assist them with special needs. I call on their primary care
physicians to discuss the needs of the members and together we setup a plan and
work together in following the plan.
I’ve experienced setting up travel to another state for a member to see a
specialist or researching the best homecare, therapy, and extended care
facilities or working with the social workers to set up long term care. I work
cohesively with the physicians, the nurses , therapists, Physicians Assistants
and Specialist as a team for each patient because we want to obtain the best
outcome.
In my history I have worked and spoken with people and these teams all over the
country, and it is the job of the Case Manager to build this team and bring them
together in behalf of the patient.
As a Case Manager, I also assist in making sure that the care that's needed is
cost effective by using my experience as a Utilization Review Nurse to determine
if the treatment and specialty meets the UR standards and criteria, and I also
discuss these cases with the Medical Directors.
I have been a Nurse Auditor for manage care companies such as Blue Cross Blue
Shield, Review Works, Great Lakes Health Plan ,and HEDIS for multiple companies.
I thoroughly enjoy the work of fact finding, details and discovery. I have
documented and summarize the findings and submitted them to the Medical
Directors.
Hedis is done for NCQA to measure the performance on important dimensions of
care and services.
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