Reviews and prepares the documentation summarizing first level appeal determination and second level appeal recommendations. Also responsible for preparing the documentation and presenting it to the second level appeal committee for final appeal determination. Responsilblities include:-Review of incoming first level provider appeals.-Evaluates the initial utilization determination and documentation.-Reviewing medical records for the days being appealed.-Compares clinical data with approved guidelines.-Determines if the determination can be changed based on the assessment of the clinical data.-Prepares notification to the facility and enters determination into database if case is decided.-If guidelines cannot be utilized, forward appeal for preparation for physician consultant review.-Prepares all second level appeal presentations for the second level appeal committee.-Utilizes databases and ensure NCQA guidelines are used to secure first level determination and second level appeal recommendations.-Uses notes and accompanying medical records to develop a clinical summary outlining the key elements of each second level appeal.-Prepares clinical worksheets to present cases to the second level appeals committee.-Presents clinical summaries to committee members for review, discussion and final determination.-Documents committee determination in minutes and on database-Forwards finalized cases for letter generation and case closure.-Participares in second level appeals committee meetings to assure time frames are consistent with the turnaround time defined in departmental and CMS policies.

Responsible for maintaining safe and therapeutic telemetry and progressive care environment perform tasks of reviewing data from special equipment to track patient’s blood pressure, heart rate, breathing and other vitalsEducate patients and their families on disease prevention, healthy diet and exercise, and lifestyle changesHandle responsibilities of implementing and directing care by using nursing process with emphasis on the needs of individual Telemetry patientsPerform tasks of evaluating the effectiveness of the nursing processResponsible for providing supervision of patient care assistant, new employees, vocational nurses, student nurses and nurse technicians participate in cardiovascular department process improvement and specific initiatives

Assess, develop, implement and communicate individualized nursing care plans and reports pertinent to the observation and patient reactions.Responsible for administering prescribed medications and perform treatment of patients as prescribed by physician.Provides acute & close monitoring of adults which includes, blood pressure, heart beat and telemetry monitoring , analyzing and interpreting data pre- & postoperative open-heart, acute & chronic disease for arrhythmias, MI screening and anticoagulation therapy.Work closely with all healthcare team members to develop treatment plans for patients to optimize patient compliance and attain healthcare goals.

Assessment• Performed total patient assessments including neurologic, cardiovascular, respiratory, gastrointestinal, genitourinary, IV site/line, PICC lines, CVP lines, surgical/trauma wound, nephrostomy tubes, tracheotomy, urinary catheters, NG tubes, G tubes and chest tubes.Planning• Educated patients and their families on disease processes, medical-surgical procedures, and board aspects of therapeutic regimens, including medication and pain management techniques.• Attended In-service training on IV and PICC line management.• As an observer, learned the legal role that chart-based medical records hold during court proceedings.Implementation• Followed aseptic procedures and provided care in accordance with universal precautions with an emphasis on surgical/traumatic wound care and debriding, intake and output, and ostomies.• Administered oral and intramuscular and subcutaneous medications.• Cared for perinatal and postpartum patients and their newborns, and evaluated fetal monitoring strips.Evaluation• Worked effectively with an interdisciplinary team, and performed accurate charting procedures.• Successfully recommended and implemented changes to the Medical Unit regarding assignment delegation and prioritization, resulting in a higher standard of patient care and reassessed/revised plan of care, as needed.