Lanita McMahon
Inver Grove Heights
Summary
Dedicated and compassionate Registered Nurse (RN) with utilization management, clinical assessment, and medical documentation expertise. Demonstrated ability to research, analyze, problem solve and resolve complex issues. Experience with state and federal regulatory policies, UM/CM/QA/Managed Care, coding (e.g. ICD-10, HCPCS, and CPT) and EMR/EPIC.
Overview
9
9
years of professional experience
1
1
Certification
Work History
RN Care Manager Retrospective
Blue Cross Blue Shield of Minnesota
07.2023 - Current
- Accountable for timely and comprehensive review of clinical data with concise documentation, decisions and rationale, according to regulatory standards and procedures.
- Apply clinical experience, health plan benefit structure and claims payment knowledge to retrospective reviews by gathering relevant and comprehensive clinical data through multiple sources
- Leverage clinical knowledge, business rules, regulatory guidelines and policies and procedures to determine clinical appropriateness
- Monitor and analyze the delivery of health care services. Evaluate appropriateness of code submission on facility and professional claims and complete unspecified code and modifier code reviews.
- Completes review of both medical documentation and claims data to assure appropriate resource utilization. Identification and resolution of quality issues and inappropriate claim submission.
- Maintains confidentiality of member and case information by following corporate and divisional privacy policies.
RN Complex Case Management Specialist
Blue Cross Blue Shield Minnesota
11.2021 - 07.2023
- Apply key principles of case management to research and analyze members' health needs and healthcare cost drivers. Utilize clinical expertise, critical thinking skills, and business sense to engage with members and their families in avoiding unnecessary hospitalizations and emergency department visits. Optimize site of care and ensure evidence-based treatment is being applied. Collaborate and communicate with interdisciplinary healthcare teams, members, families, and providers to promote positive clinical results and high-quality, cost-effective outcomes. Maintain a high level of customer service throughout all points of contact.
RN Care Manager Appeals
Blue Cross Blue Shield Minnesota
11.2020 - 11.2021
- Manage and resolve appeals from members and providers, ensuring compliance with regulations and guidelines. Conduct thorough medical documentation review to evaluate the appropriateness of healthcare services. Collaborate with interdisciplinary teams to improve provider performance and member satisfaction.
RN Care Manager Pre-service
Blue Cross Blue Shield Minnesota
11.2017 - 11.2020
- Implementation of effective utilization management strategies including review of appropriateness of preservice health care services, application of criteria to ensure appropriate resource utilization, and resolution of quality issues. Monitor and analyze the delivery of healthcare services; educate providers and members on a proactive basis and survey qualitative and quantitative data to improve provider performance/satisfaction and member satisfaction.
Perioperative RN
Summit Orthopedics
10.2016 - 10.2017
- Functioning in a charge role - coordinating staff, surgeons, equipment, and supplies. Ensuring safe, efficient management of the daily orthopedic and orthopedic spine surgery schedule. Clinical role - circulate as a perioperative nurse for all general orthopedic, sports medicine, orthopedic spine, total shoulder, total knee, and total hip surgical procedures performed in the ambulatory surgery center.
Staff Nurse, Operating Room
United Hospital
06.2016 - 10.2016
- Circulate as a staff nurse in a 15-suite surgical department. Provide specialized nursing care as a member of the Neurosurgery, Ear Nose and Throat and General Surgical specialty teams. Care for specimens and cultures as directed by facility set policies and procedures.
Staff Nurse, Operating Room
Hennepin County Medical Center
12.2015 - 05.2016
- Circulate as a staff nurse in a 17-suite surgical department. Responsible for providing age and culturally appropriate care, comfort and support to pre and intraoperative patients. Provide specialized nursing care in a variety of surgical specialty areas including General, Pediatric, Neurological, Orthopedic, Podiatric, Ophthalmological, Gynecological, Urologic, Ear Nose and Throat, Oral/Maxillofacial, Dental, Reconstructive Plastic / Burn, Cardiovascular, Urologic and Trauma.
Education
Bachelor of Science in Nursing -
Capella University
Minneapolis, MN08.2020
AORN Perioperative 101 - undefined
Anoka Technical College
Anoka, MN08.2015
Associate Degree in Nursing - undefined
Inver Hills Community College
Inver Grove Heights, MN05.2015
Skills
- Experienced registered nurse
- Utilization management expertise
- Clinical documentation assessment
- Health benefits analysis
- Medicare reimbursement management
- Medicare coverage analysis
- Skilled in healthcare coding systems HCPCS and CPT
- Perioperative Circulator
- Patient evaluations
- Interdisciplinary Collaboration
Certification
- Registered Nurse / Minnesota State Board of Nursing License # 227967-7
Timeline
RN Care Manager Retrospective
Blue Cross Blue Shield of Minnesota
07.2023 - Current
RN Complex Case Management Specialist
Blue Cross Blue Shield Minnesota
11.2021 - 07.2023
RN Care Manager Appeals
Blue Cross Blue Shield Minnesota
11.2020 - 11.2021
RN Care Manager Pre-service
Blue Cross Blue Shield Minnesota
11.2017 - 11.2020
Perioperative RN
Summit Orthopedics
10.2016 - 10.2017
Staff Nurse, Operating Room
United Hospital
06.2016 - 10.2016
Staff Nurse, Operating Room
Hennepin County Medical Center
12.2015 - 05.2016
AORN Perioperative 101 - undefined
Anoka Technical College
Associate Degree in Nursing - undefined
Inver Hills Community College
Bachelor of Science in Nursing -
Capella University
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