Qualifications

Five years of plastic and reconstructive patient care in an office setting.

Eight years of broad-based surgical experience in an academic hospital setting.
Eight years of multifaceted experience in Managed Care for all lines of business
.
Dedicated to the provision of a quality service that is patient-oriented and fle
xible
enough to meet the needs of all parties involved.
Work History
February 2010a"present Prior Authorization Nurse at Aetna. Presently working i
n the Prior Auth Department, Medicaid line of business. Authoriz
ing requests for: Surgery, Medical, DME, Ambulance, Home care and outpatient re
habilitation requests.
June 2005 a"present, Plastic Surgery Nurse, Penn Plastic Surgery Outpatient Prac
tice, The Hospital of the University of Pennsylvania. Responsible for care of p
lastic and reconstructive surgery patients, free flap breast reconstruction pati
ents and assists with minor procedures, including Botox, Restylane and Juvederm
injections. Responsible for telephone triage of patient issues, working with Adm
inistrative Assistants and with the nursing team to provide appropriate coverage
of office hours. Communication with outside Clinical Research Personnel, Medica
l and Surgical Teams, Sales Representatives and Visiting Professors. Plastic su
rgery office nurse for Dr. Joseph Serletti, Chief of Penn Plastic Surgery Depart
ment and for Dr. Scott Bartlett, Chief of Plastic Surgery Department at the Chil
dren's Hospital of Philadelphia. I assisted all the Plastic Surgery Attendings
with patient care on clinic days as needed.
April 2004-June 2005, Provider Auditor II, Corporate Financial investigations De
partment, Independence Blue Cross. Identify payment methods and factors used in
reimbursing targeted claims and determine applicable audit methods. Screen and
analyze audit samples in summary and in detail to select claims for audit. Revi
ew medical and billing records to identify errors in factors that determine or i
nfluence payment. Document and substantiate billing errors to providers and nego
tiate resolution. Initiate and verify claim adjustments, maintain audit document
ation and prepare statistical data.
October 2001-2004, Cosmetic Review: Senior Patient Care Coordinator, Patient Car
e Management Department, Independence Blue Cross. Precertification of cases fo
r all lines of business for the Cosmetic Review Department. Presented Cosmetic
Review in-service for managed care associates. Reviewed hospital and provider
claims for billing errors and correct ICD-9 and CPT codes. Communicated directly
with all associates in Care Management & Coordination department and facilitate
d member's understanding of plans of care for in network and out of network req
uests. Met quality assurance guidelines 98-100% each month.
September 1999-2001, Grievance Nurse, Patient Care Management Department, Indepe
ndence Blue Cross.
Coordinated and processed first level grievance appeals and thi
rd level grievance appeals for external review for the HMO line of business and
Government Programs according to Act 68 State regulations. Communicated with th
e Department of Insurance, Department of Health and selected external review or
ganizations to facilitate determinations and complete appeal reviews. Preceptor
to the managed care staff. Met quality assurance guidelines 95- 100% per mont
hly audits.
January 1997-September 1999, Patient Care Coordinator, Patient Care Management D
epartment, Independence Blue Cross. Precertification for all lines of HMO busin
ess-Commercial and Government Programs. In addition, other responsibilities we
re clinical documentation in the appropriate systems, referrals to Medical Direc
tors and the timely communication of determinations. Responsible for precepting
new hires and coordinating their activities with the Staff Development Departme
nt. Met quality assurance guidelines 95-100% each month per telephone audit by
supervisor.

January 1995-January 1997, Level III Staff Nurse, Ambulatory Procedure Unit, Hos
pital of the University of Pennsylvania. Responsible for post-anesthesia care
of surgical patients and medical patients undergoing same day procedures in the
Ambulatory Procedure Unit, Bronchoscopy Suite and Gastrointestinal Suite. Serve
d as occasional charge nurse. Clinical Instructor for Intravenous and Phlebotom
y certification course.
July 1989-January l995, Level II Staff Nurse, Day Surgery Unit, Hospital of the
University of Pennsylvania. Responsible for performing both circulation and scr
ub nurse duties in various surgical areas with a specialization in orthopaedic s
urgery, plastic surgery, gynecology, ophthalmology and otorhinolaryngology. Rot
ated weekend call for the In-Vitro Fertilization Suit. Trained and certified in
the operation of lasers. Preceptor for new staff members in orthopaedic surger
y area.
Jaunuary 1984-July 1989, Level II Staff Nurse, Intravenous Team, Hospital of the
University of Pennsylvania.
Responsible for intravenous care of medical, surgical, neurolo
gical, kidney & liver transplant and obstetrical patients. Responded to calls f
or specific needs in SICU and MICU. Instructor for Intravenous Certification co
urse for the nursing department.
May 1979-October 1983, Level II Staff Nurse, Neonatal Intensive Care Unit, Hospi
tal of the University of Pennsylvania. Responsible for direct patient care of cr
itically ill ventilator-dependent neonates and infants. Organized parent teachi
ng related to hospital care and home care. Acted as frequent charge nurse and o
riented new staff members.
Education:
Bachelor of Science in Nursing, Holy Family College, 1979
Licenses & Certificates:
CPR-BCLS certification 2009

Current active RN licensure in PA (RN-23227 I -L) since 1979