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LaToya
colehughes79@yahoo.com
205-381-6478
164 Chelsea Park Road
Chelsea, AL 35043
RN
15 years experience W2
0
Recommendations
Average rating
195
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Summary

  • Experienced nursing professional with clinical experience, leadership abilities, and technological knowledge.
  • Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
  • Quality-driven and efficient, with excellent interpersonal skills.
  • Capable of working efficiently unattended while swiftly learning new skills.
  • Experience evaluating medical records using clinical knowledge and critical thinking skills to interpret and apply medical policies, guidelines, and benefits.
  • Ensuring that a procedure or service satisfies the criteria for coverage by applying clinical knowledge in accordance with the member's benefit agreement and guidelines.
  • Collaborated with providers to obtain required clinical information, supporting prior authorization determinations, and individual inquiries when needed to decide and determine the next step.
  • Determined whether the medical services provided to members are medically appropriate by conducting prospective, concurrent, and retrospective reviews.
  • Remained up to date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
  • EDUCATION: Bachelor of Science (B.S.), Health Sciences, Southern New Hampshire University; Associate of Science in Nursing, Central Alabama Community College; Associate of Applied Science in Administrative Office Applications, Jefferson State Community College
  • CERTIFICATION: RN/MSL 1-160377; RN/SSL 1-160377

Experience
Education
Bachelor's in Health Sciences
Southern New Hampshire University
Associate's in Nursing
Central Alabama Community College
Associate's in Administrative Office Applications
Jefferson State Community College
Certifications
RN/MSL
2025
RN/SSL
2020
Skills
Registered Nurse
2025
10
Documentation
2025
9
CASE
2025
6
Employee Benefit Plans
2025
6
inbound calls
2025
6
Medical Review
2025
6
Medicare
2025
6
Problem Solving
2025
6
Project Assistant
2025
6
Utilization Review
2025
6
Benefits
2025
4
Case Management
2020
4
Medical Records
2025
4
Project Management
2025
4
Administrative Support
2017
3
Compliance
2020
3
Human Resource
2017
3
Nursing
2020
3
Supervisor
2018
3
Appeals
2020
2
Billing
2013
2
Patient Relations
2013
2
Progress
2013
2
Regulatory Reporting
2017
2
Assessment
2018
1
Cabling
2020
1
Catheter
2018
1
Diagnostic Tests
2018
1
Diagnostics
2020
1
Infection Control
2018
1
Medical Devices
2018
1
Microsoft Word
2020
1
MS Word
2020
1
Physician
2018
1
Surgical Nursing
2020
1
Training
2018
1
Windows
2020
1
Customer Deliveries
2014
1
Implementations
2023
1
Marketing
2023
1
Microsoft Excel
0
1
Motion
2018
1
MS Visio
2017
1
Presentation
2023
1
Spring
2020
1
Swift
0
1
Languages
English, Fluent/Bilingual