Marion Coleman- Lyons
Rancho Santa Margarita,CA
Summary
Versatile LVN, offering more than 15 years of diverse hands-on professional and 10 years Utilization/Case Management experience. A passionate Clinical Reviewer, self- motivated and driven towards facilitating evidenced-based and cost-efficient, quality care. Often described as a detail - oriented and resourceful by collegues, this medical professional is able to make appropriate decisions in high pressure environments by utilizing proven clinical knowledge, natural interpersonal strengths, and technical abilities to aide in fostering rapport with members, providers, and insurance carriers for optimal outcomes. Highly motivated and compassionate, critical thinking problem-solver seeking a position where knowledge and new skills can be acquired all while utilizing present skills, talents, and experience.
Overview
14
14
years of professional experience
1
1
Certificate
Work History
Utilization Management Nurse- Outpatient
Optum- Desert Cities
Palm Desert, California
09.2018 - 09.2022
- Performed prior authorization review of cases requiring notification. >100 cases/daily
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Submitted cases to Medical Director for criteria failures and helped facilitate resolutions and approvals. 10-25 cases/daily
- Devise or identify solutions for irregular requests and issues.
- Facilitated workgroup meetings with Medical Management team members to find effective solutions to issues. Monthly
- Evaluated patient histories, complaints and current symptoms.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Participated in Executive Medical Management policy committee to discuss policies, propose revisions and implement changes. Quarterly
- Strengthened training and nursing knowledge by taking part in continuing education programs and Advanced UM workshops. On-going
- Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
Utilization Review Nurse- Inpatient
Med Search Staffing For IEHP
Ontario, California
01.2018 - 08.2018
- Evaluated patient histories, complaints and current symptoms.
- Accurately documented treatment, medications and IVs administered, discharge instructions and follow-up care.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed admission reviews based for medical necessity based upon MCG, InterQual, and HP specifications. 10-25 cases/ daily
- Assessed and evaluated mental health needs, working with multidisciplinary team to initiate, manage and modify individualized care plans.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
Utilization Review Manager- Residential/PHP/IOP
West Coast Recovery Centers
Hemet, California
10.2015 - 09.2017
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification. 10-15 cases/ daily
- Performed admission reviews based for medical necessity based upon SAMHSA, ASAM, and Health Plan specifications. 3-5 cases/ daily
- Served as subject matter resource, providing information related to Treatment Center policy and implementation.
- Supported or performed clinical appeals through Peer to Peer Review and MDT meetings. Daily
- Obtained authorizations from multiple insurance carriers for various levels of care.
Private Duty Licensed Practical Nurse
ANTCD- Private Pay Client
Moreno Valley , California
10.2010 - 06.2014
- Cared for Chronically Ill/Temporary Disabled Male Patient with substance abuse, Infectious disease, poor social supports to understand and comply with treatment regimen toward full health and wellness over course of Medical trials.
- Responded to patient requests with appropriate clinical and personal assistance. Daily
- Took samples to complete diagnostic and routine assessment tests. weekly blood draw, stool/urine samples.
- Supported physicians during examinations and scans to assist with diagnostic procedures.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions. Every 90 days
- Educated patients and caregivers on medical diagnoses, treatment options, chronic disease self-management and wound management.
- Traveled to clients' homes to complete healthcare services and promote continuity of care.
- Administered controlled narcotics, inserted IVs and performed catheterizations.
Quality Risk Management Interim Director
Vista Hospital Of Riverside
Perris, CA
09.2008 - 06.2010
- Facilitated performance improvement standards, quality control, and risk management for 92 bed acute Hospital.
- Coordinated successfully and with full compliance to prevent infections according to facility and Joint Commission standards- Annually,
- Produced and filed reports to inform senior management of current activities and progress with investigations- Quarterly
- Improved quality processes for increased efficiency and effectiveness. Reduced reportable events to below benchmark by 3 quarter.
- Managed and archived quality documentation and participated in internal and external quality audits.
- Performed in-depth research and investigations and recommended strategies to resolve problems and prevent further concerns.
- Evaluated hospital-onset and healthcare-acquired infections by conducting root cause analysis.
- Reduce EMR Documentation deficiencies by 30% trough training and process changes based on root cause analysis.
Admissions Coordinator/Resource Nurse
Valley Plaza Doctors Hospital
Perris, Cal
05.2006 - 05.2008
- Assisted in patient admission process based on federal and state laws (EMTALA).
- Provided physicians and other medical personnel with patient assessment details and answered patient care-related questions.
- Assisted floor nurses with medication administration and prescribed treatments.
- Settled incoming patients into rooms and verified adequacy of medical supplies and treatment equipment.
- Assessed new patients' care plans and administered prescribed medications and treatments.
- Directed patient admission and discharge tasks while managing patients and coordinating care.
- Advocated for and strived to protect health, safety and rights of patient.
- 96 bed LTAC facility admission/discharges 5-10 day.
Education
Bachelor of Science - Healthcare Administration
Capella University
Minneapolis, MN09.2024
Associate of Science - Health Sciences
Riverside City College
Riverside, CA12.2020
Vocational Certificate - Vocational Nursing
Concorde Career College
San Bernardino, CA08.2003
Skills
- Clinical Experience ( M/S/ICU/Tele, Psych/CD, OP Clinics)
- Utilization Management Experience ( HP, MCO, IPA, Acute Setting )
- Case Management (Inpatient/Outpatient)
- Utilization Review (Pre-service, Concurrent, Retrospective)
- Insurance Payor Knowledge ( Medicare, Medi-Cal, Medi-Medi, HMO, PPO)
- Appeals/Grievances
- Clinical Resource Development and Trainer
- Data Collection and Clinical Documentation
- ICD-10, HCPCS, DRG Coding
- CMS, MCG InterQual, and/or Payor Medical Policy
- Clinical Denials, Appeal Rights, Claims Review
- Benefit/Eligibility Application
- Strong Organization and Time Management
- Collaborative Problem Solving
- Interpersonal Communication, Cultural Competence, Provider Relations
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Certification
- Licensed Vocational Nurse - California BVNPT VN-208336 2003- Current
Quote
Intelligence is the ability to adapt to change.
Stephen Hawking
Timeline
Utilization Management Nurse- Outpatient
Optum- Desert Cities
09.2018 - 09.2022
Utilization Review Nurse- Inpatient
Med Search Staffing For IEHP
01.2018 - 08.2018
Utilization Review Manager- Residential/PHP/IOP
West Coast Recovery Centers
10.2015 - 09.2017
Private Duty Licensed Practical Nurse
ANTCD- Private Pay Client
10.2010 - 06.2014
Quality Risk Management Interim Director
Vista Hospital Of Riverside
09.2008 - 06.2010
Admissions Coordinator/Resource Nurse
Valley Plaza Doctors Hospital
05.2006 - 05.2008
Bachelor of Science - Healthcare Administration
Capella University
Associate of Science - Health Sciences
Riverside City College
Vocational Certificate - Vocational Nursing
Concorde Career College
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