Cassie Carey

Experience

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  United States Army

  Nov 1997 - Nov 2009

  Sergeant

  Squad Leader/Section Chief/Military Nurse: Deployed 2003 – 2005. Judgment, Supervision, Informing Others, Nursing Skills, creating a Safe, Effective Environment, Hospital Environment, Medical Teamwork, Listening, Pain Management, Administering Medication, Adult Health, Processing Soldiers. Maintained sufficient, qualified staff with which to operate the unit, budgeting the unit’s expenditures in accordance with available funds, ensuring patient issues are promptly and correctly addressed, and supervising all other routine operations of the unit, as well as any unforeseen occurrences that may arise. Encompassed features of leadership and administrative methods associated with the broad facets of the military nursing profession. Tasked with overseeing the continued optimal functioning of the unit as well as the quality of the health care provided by nurses and other medical personnel. Kept up with departmental or facility-wide policy changes and ensure compliance with these policies within their department. My role in the Army was a predominantly supervisory/management position, which required a military nurse who possessed strong organizational skills, leadership ability as well as clinical nursing knowledge. Show less

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  The Salvation Army

  Sept 2009 - Aug 2010

  Night Manager Charge Nurse

  NIGHT MANAGER/CHARGE NURSESalvation Army Clitheroe Detox & Rehab Report directly to medical unit supervisor to communicate floor status. Train and manage staff nurses in areas of assignment delegation, scheduling and patient relations. Supervise the emergency use of the crash cart during seizures, cardiac and respiratory arrest. Manage life threatening complications exercising strong observation, assessment and intervention skills. Provide acute care for detox patients from initial assessment through recovery phase. Perform clinical procedures utilizing various invasive/noninvasive monitoring equipment. Administer daily and detox medications; educate patients/families on treatment, prevention and medication. Show less

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  ABQ Health Partners

  Sept 2010 - Oct 2012

  Team Lead Manager

  Cardiology; Pediatrics; Primary Care; Urgent Care; Utilization Management: Was responsible for the personnel, resources and patient care on a group of units within a healthcare institution. Carried out complex leadership responsibilities that directly affected the quality of care to patients and families. Promoted and restored patients' health by developing day-to-day management and long-term planning of the patient care area; directed and developed staff; collaborated with physicians and multidisciplinary professional staffs; provided physical and psychological support for patients, friends, and families. Identified patient service requirements by establishing personal rapport with potential and actual patients and other persons in a position to understand service requirements. Maintained nursing operations by initiating, coordinating, and enforcing program, operational, and personnel policies and procedures. Assured quality of care by developing and interpreting clinical and nursing division's philosophies and standards of care; enforcing adherence to state board of nursing and state nurse practice act requirements and to other governing agency regulations; measuring health outcomes against standards; making or recommending adjustments. Maintained nursing staff by recruiting, selecting, orienting, and training nurses and auxiliary staff. Completed patient care requirements by scheduling and assigning nursing and staff; following up on work results. Maintained nursing staff job results by coaching, counseling, and disciplining employees; planning, monitoring, and appraising job results. Ensured team meets established performance metrics and performance guarantees. Managed clinical operations across the continuum of care to include assessing, planning, implementing, coordinating, monitoring and evaluating health care delivery. Show less

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  Presbyterian Healthcare Services

  Nov 2012 - Aug 2014

  Team Lead Supervisor

  TEAM LEAD SUPERVISOR: Presbyterian Medical Group: Responsibilities included leadership role, nursing assessment and visits, clinical role under the supervision of Dr. Ahuja assisting doctors with outpatient services, direct patient care, taking vital signs and noting symptoms before the physician's examination, IV, Immunization, medication administration, and telephone and walk-in triage to assist patients with emergency and crisis health issues, worked with insurance companies to ensure a patient's treatment and care is covered through prior authorization. Maintained nursing supplies inventory by studying usage reports; identifying trends;anticipating needed supplies; approving requisitions and cost allocations. Accomplishments included being a team leader, have a vast amount of knowledge and nursing skills that allowed me to step into any role, and training both internal and external nurses. Maintained documentation of patient care services by auditing patient and department records. Managed clinical operations across the continuum of care to include assessing, planning, implementing, coordinating, monitoring and evaluating health care delivery. Show less

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  Brookdale Senior Living

  Aug 2014 - Apr 2015

  Health and Wellness Director

  Director of Assisted Living: Responsible for the direct supervision of community-based nursing staff, med tech, and resident care associates. Assigns and directs work of subordinates, appraising performance, rewarding and disciplining associates, addressing complaints and resolving problems. Provides training, supervision, and monitoring of associates, auditing charts and MAR, assesses health, functional and psycho-social status of residents, initiates individualized service plans, proactively manages care, completes pre-admission screening, scheduling per service alignment. Hiring, retaining, and terminating employees. My position required knowledge of health policies and practices, managerial skills, and leadership experience. The position of health and wellness director consisted of managing staff, implementing strategies and having a passion for planning programs that benefit health, safety and well-being. I did an enormous amount of delegation and communication both inside and outside of the company. Directing the Assisted Living required a keen business sense and knowledge of effective marketing strategies to ensure the most valuable outcome for the residents and company. Show less

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  Lovelace Health System

  Apr 2015 - Jan 2016

  Clinical Liaison Territory Manager

  Responsibilities included combining nursing assessment, clinical critical thinking, with marketing by traveling to hospitals to assess patients and sale them on Rehab. Accomplishments included brought new marketing techniques to my team. As a clinical nurse liaison I established patients' eligibility for care, communicated with families, and interacted with a wide range of staff members, from admissions coordinators to case managers to physicians. Nurse liaisons advocate for patients in a health care facility beginning with the pre-admission process and following through their release. As a nurse liaison I fostered the relationship between patients and the facilities providing their care. As a nurse liaison I was the first to assess patients, review their medical records, and determine whether they should be admitted for care. I explained the types of care and services the facility offers to patients and their families. I also worked with the facility to schedule therapy sessions and doctor visits. Coordinating with other staff members to ensure smooth patient discharge was also among my duties. I also verified health insurance and its coverage, while interacting with the providers and the facility. Other duties included training other staff members and consulting with the facility's sales division. Show less

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  Presbyterian Healthcare Services

  Jan 2016 - Oct 2017

  Utilization Manager

  UTILIZATION MANAGEMENT REVIEW NURSE LEADER LONG TERM CAREReview and Analyze records to determine if members meet criteria for Long Term Care and Self Directed Community Benefits. My primary responsibility as a utilization review nurse is to review medical records and prepare clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for Medicaid patients. I have an understanding of the severity of an array illness, intensity of service, and care coordination needs, as a nurse I must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the patient. I work with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings. I also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation. Analyze information gathered by investigation, and report findings and recommendations. Modify patient treatment plans as indicated by patients' responses or case history. Audit and analyze patient records to ensure quality patient care and appropriateness of services. Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims. Show less

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  Blue Cross Blue Shield Association

  Nov 2017 - Apr 2018

  Utilization Manager Medicare/Medicaid Concurrent Review

  UTILIZATION MANAGEMENT REVIEW NURSE LEADER:HCSC for MT, NM, TX, OK, and IL: Managed Care Organizations performed Utilization Review Management for both Medicare and Medicaid, worked with an integrated team of health care professionals in a fast-paced environment. Worked in different dedicated units within BCBS in a Managed Care Setting. Performed pre-certification review, admission reviews, concurrent review, retro reviews using Milliman Care Guidelines and BCBS Clinical Policy Guidelines. Coordinated with facility case managers in discharge planning and transfer of patients to the appropriate level of care using knowledge of the dedicated units benefit plan. Assessed for unnecessary services and recommended other appropriate options. Consistently demonstrated excellence in quality assurance evaluations of work production. Took initiative to work as a team with other nurses in meeting production goals. Collaborated with leadership and management in improvement measures for work processes. Received excellent anecdotal feedback from leadership leading to advancement of role. Identified services needed for members such as case management, disease management and behavioral health. Quality abstraction and auditing. Show less

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  Molina Healthcare

  Apr 2018 - Dec 2018

  Utilization Manager Medicaid/Marketplace Prior Authorization & Concurrent Review

  UTILIZATION MANAGEMENT REVIEW NURSE LEADER: Prior Authorization and Concurrent Review Nurse for Medicaid and Marketplace. Performed utilization review activities, including precertification, concurrent review, retrospective reviews, appeals, and quality audits according to CMS, HSD, and NCQA guidelines. Determined the medical necessity of requests by performing first level reviews using approved evidence-based guidelines/criteria. Answered Utilization Management directed telephone calls; managing them in a professional and competent way. Referred cases to reviewing physician when the treatment request did not meet necessity per guidelines, or when guidelines were not available. Conducted and documented rate negotiations with out of network providers, utilizing appropriate reimbursement methodologies. Identified and referred potential cases to Disease Management and Case Management appropriately for proper follow up. Worked with the Utilization Management team primarily responsible for prior authorization necessity/utilization review and other utilization management activities aimed at providing Healthcare members with the right care at the right place at the right time. Provided daily review and evaluation of members that require clinical care and/or procedures providing prior authorization. Assessed services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Identified appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. NCQA experience; InterQual and Milliman (MCG) experience. Maintained documentation of patient care services by auditing patient and department records. HEDIS abstraction and quality review. Eight months of 100% audits regarding documentation privacy, accuracy and timeliness in accordance with Molina policy & procedures. Quality abstraction and audits. Show less

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  Centene Corporation

  Dec 2018 - Feb 2020

  Utilization Manager Medicaid/Medicare

  UTILIZATION MANAGEMENT REVIEW NURSE LEADER: Concurrent Review, Prior Authorization, Appeals, and Behavioral Health. Performed utilization review activities, including precertification, concurrent review, retrospective reviews, appeals, and quality audits according to CMS, HSD, and NCQA guidelines. Utilization Review Manger competent at assuring the receipt of high quality and cost efficient medical outcomes. Identify the need for inpatient and outpatient precertification and preauthorization. Screen enrollees for ICM programs. Review precertification requests for medical necessity and refer those requests that require additional expertise to the Medical Director. Review clinical information for concurrent reviews and extend lengths of stay as appropriate. Utilize effective relationship management, coordination of services, resource management, patient advocacy, education and related interventions. Provide appropriate consultation to patients and refer patients to Case Management personnel when necessary. Quality audits with CMS, HSD, and NCQA guidelines. Show less

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  Molina Healthcare

  Mar 2020 - now

  Medical Claim Review Nurse Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. Identifies and reports quality of care issues. Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience. Documents clinical review summaries, bill audit findings, and audit details in the database. Provides supporting documentation for denial and modification of payment decisions. Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge. Profound knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care. Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions. Serves as a clinical resource for Utilization Management, Physicians, and Appeals. Provides training and support to clinical peers. Worked Clinical Review for Appeals to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Show less Clinical Appeals Nurse is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards. Performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made or upon request by another Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care. Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) cases and with Marketplace EOCs (Evidence of Coverage). Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer on denial decisions. Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues. Identifies and reports quality of care issues. Prepares and presents cases in conjunction with the Chief Medical Officer for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers. Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required. Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals. Provides training, leadership and mentoring for less experienced appeal LVN, RN and administrative staff. Clinical nursing experience, with 13 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review, Medical Claims Review Experience demonstrating knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines. State Fair Hearing and Case Summary completion. Show less Care Review Clinician Prior Authorization: Prior Authorization Review Nurse with previous experience in Prior Authorizations, Utilization Review /Utilization Management and knowledge of Interqual / MCG guidelines. Excellent computer multi-tasking skills and analytical thought process and adhered to and met productivity turnaround times. As a Care Review Clinician Nurse working at Molina Healthcare Services (HCS) worked with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. As a HCS Nurse worked to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Assessed services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Analyzed clinical service requests from members and/or providers against evidence based clinical guidelines. Identified appropriate benefits and eligibility for requested treatments and/or procedures. Conducted prior authorization reviews to determine financial responsibility for Molina Healthcare and its members. Processed requests within required timelines. Referred appropriate prior authorization requests to Medical Directors. Requested additional information from members or providers in consistent and efficient manner. Made appropriate referrals to other clinical programs. Collaborated with multidisciplinary teams to promote Molina Care Model. Adhered to UM policies and procedures.1-3 years of hospital or medical clinic experience. Show less

  • Medical Claim Review Appeal Nurse

    Jun 2022 - now

  • Clinical Appeals Nurse

    Jun 2021 - Jun 2022

  • Utilization Manager

    Mar 2020 - May 2021