KImberlee NICHOLE beal
Cumberland
Summary
Highly organized, detail-oriented, and self-directed professional with expert communication skills and quality auditing experience. Offering a 29-year nursing history, I currently serve as a Senior Clinical Quality RN representing Utilization Management in external-facing client audits. Recognized as a top performer, I possess proven capabilities to excel and work independently.
Overview
20
20
years of professional experience
2
2
years of post-secondary education
Work History
Senior Clinical Quality RN
United Healthcare
Cumberland
04.2023 - Current
- Clinical expertise in utilization management process, evidence-based guidelines and the system matrix
- Representation of Utilization Review during external facing Commercial client audits
- Flexible and self-directed with ability to manage priorities effectively for timely project deliverables
- Effective communication skills presenting to internal and external stakeholders during audit activities
- Analysis of utilization patterns to identify gaps in process with recommendations for remediation
- Accurate documentation of assessments in Logic
- Team collaboration to discuss file trends, process and consistency
Inpatient Care Manager
UnitedHealthcare
Cumberland
10.2014 - 04.2023
- Performed utilization reviews for the M&R and commercial lines of business
- Support Leader and preceptor, serving and collaborating with the team/Senior Nurse and manager
- Robust DCP, SME for Downstream Referrals/Process/Documents
- Experienced with making team assignments
- Conducted medical necessity reviews based on InterQual to ensure standard of care
- Work in tandem and collaborate with Medical Director’s on cases not meeting standard of care or having extended los
- Experienced in BCRT data review
- Proficient in Microsoft office (Excel, Word, PowerPoint), ICUE, EMR
- 100% on quality audits
Adult Evaluation and Review Services-AERS (prn)
Allegany County Health Department
Cumberland
09.2020 - 01.2023
- Evaluated aged and functionally disabled adults at risk for being institutionalized
- Forecasting needs
- Referrals to programs for enhanced well-being
Clinical Care Manager
Aetna
New Albany
07.2014 - 10.2014
- Performed Utilization Review
- Worked in tandem with providers to determine plan of care
- Navigation and application of Millimen Care Guidelines
- Escalated cases to the Medical Director for case determinations
- Excelled in discharge planning from acute setting to outpatient services
Case Manager
Conifer Health Solutions
Annapolis
01.2011 - 07.2014
- Senior Nurse, provided training for staff, daily reports, audits
- Project lead for Chronic Care Improvement Project/HEDIS
- Robust discharge planning and coordination of services
- Management of complex and chronic care caseload in the commercial line of business
- Frequent broker discussions concerning high dollar treatment plans
- Review of cancer treatment plans against national standards
- Responsible for reporting cost savings
Case Manager
Nationwide Better Health
Hunt Valley
11.2005 - 01.2011
- Disease Management
- Provided patient education on chronic disease states
- Referrals to the Medical Director on potential high dollar cases
- Reviewing the insurance matrix for appropriate benefits and eligibility
- Coordination of resources and programs
Education
Bachelor of Science - Nursing
Shenandoah University
Winchester, VA 08.1996 - 05.1997
Associate of Arts - Nursing
Shenandoah University
Winchester, VA 08.1994 - 05.1996
Skills
- Clinical Auditing, perform end to end chart reviews
- Utilization process SME, evaluating guideline adherence, documentation, and quality
- Collaboration with leadership, internal and external stakeholders
- ASO clinical quality preceptor
- InterQual Guideline proficient
- Monthly IRR file review with team
- Team collaboration
- Proficient in Microsoft Office (Excel, Word, PowerPoint)
- Experienced in ICUE, and OCM platforms for case reviews
- Proficient with Logic and SmartSheets
Personal Information
Title: Certified Case Manager, Milliman Care Guideline Certified
Work Involvement
- Multi-time Bravo Award recipient for Leadership, Collaboration and Quality
- UHC Inspire participant
Timeline
Senior Clinical Quality RN
United Healthcare
04.2023 - Current
Adult Evaluation and Review Services-AERS (prn)
Allegany County Health Department
09.2020 - 01.2023
Inpatient Care Manager
UnitedHealthcare
10.2014 - 04.2023
Clinical Care Manager
Aetna
07.2014 - 10.2014
Case Manager
Conifer Health Solutions
01.2011 - 07.2014
Case Manager
Nationwide Better Health
11.2005 - 01.2011
Bachelor of Science - Nursing
Shenandoah University
08.1996 - 05.1997
Associate of Arts - Nursing
Shenandoah University
08.1994 - 05.1996