Kimberly Albertson
Motley
Summary
I am motivated to work as a team member in a highly innovative and personalized health plan with the desire to continue developing professionally. I have a solid and substantial background in utilization review, claims and appeals. I am seeking a position within your organizational Team where I can utilize this experience and skills in an efficient and productive manner.
Overview
20
20
years of professional experience
Work History
Utilization Nurse Reviewer/Appeals Nurse
Optum
11.2017 - Current
- Provide efficient, effective risk management according to each specific benefit plan for the health plan products, using utilization review.
- Perform Pre-Service and Post-Service Appeal reviews
- Collaborate with health plan administrators for out of network exceptions by assessing the most cost-effective approach and whether the medical standards and accepted practice parameters were established.
- Accurately apply benefit language to each review situation.
- Evaluated clinical documentation for compliance with medical guidelines and policies.
- Mentored junior reviewers on best practices in clinical documentation standards.
- Analyzed trends in case reviews to identify areas for quality improvement initiatives.
- In a timely fashion, contact Manager, Director and Account Manager to make recommendations for flexing or extending benefits to prevent the possibility of using more costly services with equivalent outcomes.
- Contribute to the development of improved clinical guidelines by participating in interdisciplinary committees and sharing expertise on best practices.
- Serve as a mentor to new nurse reviewers, providing guidance and support in navigating the complexities of case evaluation processes.
- Facilitate accurate decision-making in complex cases by consulting with medical specialists when needed.
PDN Clinical Supervisor
Recover Health
08.2017 - 11.2017
- Supervises patient and family care as specified by the plan of care, assessing appropriateness, continuity, service, and quality of care.
- Maintains clinical record documentation according to agency policy and procedures and state/federal regulations.
- Supervisory responsibilities include interviewing, hiring, training and terminating (with administrative approval) all interdisciplinary staff; planning, assigning, and directing work; appraising performance; rewarding and disciplining colleagues; addressing complaints and resolving problems.
- Developed and implemented training programs for new staff, enhancing onboarding processes and improving retention rates.
- Conducted regular performance evaluations, providing constructive feedback to promote professional growth among team members.
Agency Manager
Accurate Home Care
10.2015 - 07.2017
- Develop and maintain policies and procedures
- Develop a system of staff communication that ensures coordinated implementation of plans of treatment and the utilization of necessary services for comprehensive care of patients.
- Organizes and directs the Agency’s day to day operations.
- Oversaw daily operations, ensuring compliance with regulatory standards and best practices.
- Mentored staff, fostering professional development and enhancing team performance.
Clinical RN Manager
Accurate Home Care
03.2012 - 10.2015
- Develop, implement and evaluate individualized client care plans.
- Complete new admissions, assessing their conditions and needs in order to develop personalized care plans.
- Educate clients and their families on how to follow their care plans.
Registered Nurse
Accurate Home Care
10.2009 - 02.2012
- Responsible for implementing the nursing process including assessment, diagnosis, planning, goal setting, implementation and evaluation, in delivery of professional and paraprofessional services to private duty and/or pediatric home care clients.
- Accurately document cares provided in home chart.
- Communicate with physician and other health care providers regarding the health status of client and follow through with physician or prescribed instructions. Communicate appropriately with RN Case Manager.
Personal Care Attendant
MN Home Care
06.2006 - 03.2008
- Assist client in bathing, dressing, washing clothes and other activities of daily living.
- Protect and respect the dignity of client, and maintain confidentiality regarding client information.
- Provide emotional support and ensure clients’ needs are met.
Universal Worker
Woodland Good Samaritan Village
02.2007 - 08.2007
- Serve residents their meals.
- Perform a variety of general cleaning activities.
- Organize and assist with daily activities.
Client Attendant
Cardinal of Minnesota, LTD
10.2005 - 05.2006
- Provide residential service to individuals who have developmental disabilities.
- Assist with physical therapy and medication administration.
- Focus on community integration and quality of life for the clients.
Student Intern
Lakewood Health System
05.2005 - 08.2005
- Work and observe the medical field through the healthcare internship program.
- Job shadow and learn from healthcare professionals at Lakewood Health System.
- Assist with planning activities at the care center.
Education
Bachelors of Science - Nursing
College of St. Scholastica
Duluth, MN08.2010
Associate of Science - Nursing
Central Lakes College
Brainerd, MN05.2009
Diploma - Practical Nursing
Central Lakes College
Brainerd, MN03.2008
General Education - undefined
Winona State University
Winona, MN06.2005
Skills
- Utilization review
- Appeals and Grievances
- Claims Review
- Aerial/OICS/Facets/Care Navigator/Epic/Milliman Care Guidelines/Interqual
- Quality improvement
- HIPAA
- Policy compliance
- Teamwork and collaboration
- Problem-solving
- Reliability
- Excellent communication
Timeline
Utilization Nurse Reviewer/Appeals Nurse
Optum
11.2017 - Current
PDN Clinical Supervisor
Recover Health
08.2017 - 11.2017
Agency Manager
Accurate Home Care
10.2015 - 07.2017
Clinical RN Manager
Accurate Home Care
03.2012 - 10.2015
Registered Nurse
Accurate Home Care
10.2009 - 02.2012
Universal Worker
Woodland Good Samaritan Village
02.2007 - 08.2007
Personal Care Attendant
MN Home Care
06.2006 - 03.2008
Client Attendant
Cardinal of Minnesota, LTD
10.2005 - 05.2006
Student Intern
Lakewood Health System
05.2005 - 08.2005
Associate of Science - Nursing
Central Lakes College
Diploma - Practical Nursing
Central Lakes College
General Education - undefined
Winona State University
Bachelors of Science - Nursing
College of St. Scholastica
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