Mary Keith Email and Phone Number

Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare reviews for cases that did not meet criteria, maintain files and logs for all appeals and coordinate with Medical Director(s) to clarify medical determinations or clinical rationale.Gather, analyze and report verbal and written information regarding member and provider clinical appeals, including information follow up.Coordinate Fair Hearings with various internal departments and agencies as well as maintain current knowledge of NCQA and State regulations.

• Responds to member and provider denials/appeals with minimal direction• Investigates and resolves member and practitioner denials/appeals within plan, regulatory and accreditation timeframes• Prepares all denial/appeal written documentation• Documents all denials/appeals in an accurate and timely manner per policy, related follow-up activities and final outcomes in designated systems while concurrently maintaining secure, comprehensive and clearly defined files • Coordinates, communicates and integrates recommendations from impacted organizational departments as required • Provides timely assistance to members and practitioners in filing a formal appeal and ensures that members and practitioners are advised of their appeal rights • Assists with training and in-services • Maintains strict confidentiality • Maintains current knowledge of NCQA, Medicare, Medicaid, and state policies and procedures • Participates in continuing education activities, as appropriate

• Coordinated health care services provided by ancillary personnel such as home health aides, physical/occupational therapy providers, and social service workers. • Instructed patients and families on methods of positive health maintenance. • Independently provided focused one -on-one care within the home and school environment for patients at significant risk for illness or injury • Performed skilled nursing assessments of client health status, completed health histories and evaluations, and assessed living arrangements • Maintained and encourage d safety precautions, psychosocial development, age- specific goal setting and play in pediatric and adult populations.• Medication administration according to hcp order,• Performed skilled nursing procedures such as: G –tube/j-tube medication administration and feeds • Ventilator and tracheostomy dependent care, and Oxygen therapy.

Private duty care nurse with pediatric and adult clients, and clients with special needsMade skilled nursing observations of clients health status and completed nursing interventions and maintained safety precautionsMedication administration according to hcp order , nebulizer treatments, oxygen management,daily nursing assessments , skilled nursing procedures such as: g -tube and Mickey button, j- tube and enteral feeding management, tracheostomy care, colostomy care

• Performed prospective, initial, concurrent and retrospective reviews for all requested services including but not limited; inpatient admissions, facility requests, durable medical equipment (DME) and outpatient and home health services • Monitored level and quality of care of services being provided and approved • Proactively managed acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs • Monitored utilization reports to assure compliance with reporting and turnaround • Assessed member’s clinical need against established guidelines and/or standards to ensure that the level of care and length of stay was medically appropriate • Interacted and worked closely with hospitals and delegated medical groups UM department to facilitate appropriate care • Reviewed and provided oversight and intervention with discharge planning needs • Referred enrollees for case management and social services per organizational • Documented enrollee utilization and transitional care in the health plan system • Completed discharge assessments • Coordinated arrangements to meet the needs of enrollees when they were discharged home

• Rotated between Skilled Nursing, Rehabilitation, Secure Dementia and Sub-acute Units • Supervised and delegated tasks to support staff such • Provided patient care including medication administration, wound care, enteral feeding management, tracheostomy care, g -tube care, urinary catheterizations, assistance with applying prosthesis and orthosis, assisted with ADLs • Promoted socialization and conversation with patients, allowing them to express concern s in a nonjudgmental, unhurried environment. Provided interventions not only with just a nursing focus but a customer service oriented, professional, and individualized manner • Responded to all in house emergencies such as codes • Completed highly detailed documentation for Medicare reimbursement and provided accurate and timely documentation of monthly summaries and shift documentation. • Reinforced Client and family member’s education in health maintenance, disease process and prevention

• Performed mother/baby teaching, prenatal teaching (nutrition, safety precautions, warning signs, community resources), and assessed for pregnancy complications • Provided STI prevention education and counseling • Provided family planning education and counseling • Facilitated office and phone Triage • Performed exam room set -up for physicals and procedures • Prepared and administered medications • Explained correct medication usage and performed Diabetic teaching • Triaged pediatric patients • Administered immunizations to children • Provided telephonic triage to parents • Provided patient teaching in proper medication usage and immunization schedule