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Monifa
monifaramsayjames@gmail.com
954-940-2386
4249 NW 61st Ct
Coconut Creek, FL 33073
Appeals Clinical Nurse, RN
14 years experience W2
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Summary

  • Over 20 years of nursing experience in case management, utilization management, mental health, managed care, and medical-surgical fields
  • 5 years of direct appeals experience
  • Experienced in CMS reviews for appeals
  • Worked with Jiva, Seibel, and Diamond and reviewed in Pre-service, Concurrent, and Post Service
  • Currently pursuing a bachelor's in Nursing at Chamberlain University

PROFESSIONAL SKILLS

  • Interqual Certified
  • Utilization management
  • Case management
  • Advanced verbal, written communication, and organization skills
  • Proficient in Microsoft Office

Experience
Grievance and Appeals Nurse
Healthcare
Dec 2016 - Apr 2020
Sunrise, FL
  • Processed appeals and determinations
  • Performed Clinical Review
  • Composed resolution letters
  • Developed new Overturn process for department
Appeals Nursing Clinical reviews Prior Authorization Clinical Review
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Prior Authorization Nurse
Healthcare
Dec 2012 - Dec 2016
Sunrise, FL
  • Performed clinical reviews of authorization requests using appropriate criteria
  • Provided accurate and complete documentation with the rationale used to approve request
  • Processed over 30 cases a day
  • Multitasked between computer and multi-line phone requests
  • Entered and maintained clinical information in multiple health management systems
Nursing Clinical reviews Prior Authorization Clinical Review
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Prior Authorization Nurse
Insurance
Dec 2008 - Dec 2012
Davie, FL
  • Performed clinical reviews of authorization requests using appropriate criteria
  • Provided accurate and complete documentation with the rationale used to approve request
  • Processed over 30 cases a day
  • Multitasked between computer and multi-line phone requests
  • Entered and maintained clinical information in multiple health management systems
Nursing Clinical reviews Prior Authorization Clinical Review
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Edit Skills
Non-cloudteam Skill
Education
Bachelor's in Nursing/Registered Nurse
Chamberlain University, 2019 - 2020
Associate's in Nursing
Jersey College of Nursing, 2016 - 2019
Certifications
Interqual Certified
RN Florida license
Skills
Clinical Review
2020
12
Clinical reviews
2020
11
Nursing
2020
11
Prior Authorization
2020
11
Appeals
2020
3
Case Management
0
1
CDI Coding
0
1
Health Services Administration
0
1
Mental Health
0
1
Patient Safety
0
1
Registered Nurse
0
1
Surgical Nursing
0
1
Triage
0
1
Utilization Review
0
1