Victoria Robinson, RN

28128 Berkshire Dr.

Southfield, Michigan 48076
248-357-2577-H
248-224-7643-cell
Objective: Searching for position in Case Management in Manage care and Worke
r's Compensation /Utilization Review/ Chart Auditor /Coding / RN Appeals Analyst
(I am a Hard Working Dedicated Nurse)
12/2007 - Present Aetna Medicare Insurance
Telephonic Case Management Nurse Consultant
Assessment of member's health status and care coordination needs.
Review of inpatient and discharge planning.
Identify members that may benefit from case management intervention.
Development and implementing of care plans.
Monitor and evaluate the plans involving the Medical Director
as indicated.
Apply case management concepts to complex issues in using problem
solving techniques to promote optimum patient outcomes.
Evaluate and identify healthcare service needs using clinical
knowledge to assure member receives care in the most appropriate setting.
Advocate for members, assist them in use of healthcare programs and provide pati
ent education.
Evaluate member's progress in meeting care plan goals, revise and
coordinate plan as needed with physician accordingly.
5/2007 - 12/2007 Traveler's Insurance
Worker's Compensation
RN Telephonic Medical Case Manager
Contact with Injured worker, Employer, and Physicians to ensure maximum
medical recovery. Manage and coordinate medical treatment.
Review of medical documentation.
Set up Independent medical evaluations, vendors or second opinions as needed.
Data entry and ensure all field s are accurate.
Coordinate and facilitate return to work including the development of
Transitional or modified job opportunities.
Provide good customer service.
Provide quality cost effective medical treatment plan to manage the claim to
the best possible outcome.
(Traveler's left the state and closed office.)

9/2006 - 5/2007 Karmanos Cancer Center

Care Management Specialists
Utilization Review using Interqual guidelines for inpatient admissions.
Reviews are faxed or Telephonic. Case management and discharge planning for
CM approved Homecare, IV infusing, and DME equipment according to criteria.
CM taught indications for medications and managing illness and disease.
Audit charts on discharges to set the hospital fee. Audit charts for retro revie
w.
Set up appointments for patients to return to the Oncology clinics.
I had case management team meetings with the Oncologists, Physician Assistants,
Nurses and Therapist.

Michigan Peer Review Organization

 UR Telephonic Nurse (Medicaid) for the State of Michigan
2/2006 Performed Telephonic Utilization Review with state guidelines and INTERQU
AL criteria for inpatient
Admissions, per DRG and 15 day re-admissions per state guidelines.
Setup appeals for the physicians by specialty.
Telephonic Reviews, Retro reviews, with input of information into the Computer S
ystem.
Michigan Peer Review Organization is contracted by the state of Michigan to hand
le Medicaid manage care throughout the state.
Reviewed charts from Providers for criteria and to assist Medical Directors with
appeals.
9/2004 - 5/2005 CAPE Health Plan
UR Telephonic Nurse - MEDICAID
Telephonic Utilization Review with INTERQUAL criteria for inpatient admissions
per 15 day DRG
and readmissions according to state guidelines.
Computer input of telephonic reviews and faxes.
I assisted with discharge planning for hospitals, skill care facilities and LTA
C.
Reviewed charts for appeals, submit findings of criteria met or not met in form
of a synopsis and sent to the medical director for review.
(Company closed.)

9/2004 ReviewWorks
Medical Review Specialist

Review auto insurance claims/charts for information of medical relatedness to in

juries.
I Coded Services and Medical diagnoses according to ICD-9, CPT, and HCPCS.
Re- coded as necessary and sent letters explaining why service codes have been
down graded or upgraded.
I DID CHART REVIEWS TO DETERMINE PAYMENT SET BY THE STATE SCHEDULE FEE TABLE.
We Audited 90 charts per month for multiple insurance companies.
Coded Services, Used Encoder Pro. HCPCS, CPT, ICD-9, NDAS /2004

1998-Present Healthcare Professionals/Maxim Agency

UR/Case Management
I performed Telephonic Utilization Review for hospital admissions and length of
stays with Medical criteria.
Use: INTERQUAL, MPRO, Millman and Roberts. Did Charts audits,
Case Manage DME equipment, homecare, and nursing home placements
. Assignments with multiple insurance companies:
BLUE CROSS/BLUE SHIELDS, HEALTH ALLIANCE PLAN, DETROIT
MEDICAL CENTER CLINIC PLAN -MEDICAID, GREAT LAKES HEALTH
PLAN MEDICAID. Wellness Plan

09/1999-5/2000 North Oakland Medical Center

Telephonic Case Manager/ UR Nurse
 Utilization Reviewed on medical charts to obtain approval for inpatient length
of stay per criteria.
Contact insurance companies to give telephonic reviews and criteria for admissio
ns.
Discharge planning. Work with Physicians and teams in planning patient's dischar
ge.
Coordinate homecare, durable medical equipment, or nursing home placement, homec
are PT/OT/Speech.
.
Hospital has been searching for large medical group to buy it.

Medical Experience:
Michigan Health Corp /Michigan Osteopathic Hospitals - PSYCHIATRIC Nurse / OR NU
RSE 1987 - 1992
Detroit Receiving Hospital 1982- 1987 - 1992 (FULL TIME 4 YEARS TO CONTINGEN
T 1YEAR)
GREAT LAKES REHAB Hospital - Floor Manager
Northville State Hospital - Psychiatric Nurse 1986-1987
Cranbrook Nursing Home - Assistant Director of Nursing
ALPHA MANOR - DON
Arnold Nursing Home - Started as Supervisor and then to Assistant Director of Nu
rsing - No longer open, owners closed.

Education: Henry Ford College

Associate of Science in Nursing 1992
Detroit Practical Nursing 1981
Licensure: State of Michigan License Registered Nurse

Cover Letter:
 Victoria Robinson, RN
28128 Berkshire Drive
Southfield, MI 48076
248-357-2577 -h
248-224-7643-c
mernetta@yahoo.com
Dear Employer,
I am a Nurse with a lot of experience in Telephonic Case Management.
I have experience in the Hospital, LTAC, and Manage care insurance companies, F
ield Case Management and Worker Compensation, and Audit Review Specialist.
I am dedicated to the care of people and making sure they are educated about the
ir illnesses and Disease. By following physician's orders and educating those
that needed it on how to care for self care, and giving explanation as to why it
is all important in maintaining healthy lives.
I feel good as a Nurse when patients understand and can give me feedback and are
able to be self directed in their care. In assisting our members I have been ab
le to go above and beyond what is expected by the company. This is due to my exp
erience as a CM in the hospital's, LTAC, and Inpatient / Outpatient Case Managem
ent in Oncology. I been have able to reach out to other resources in the members
area to assist them with special needs, and I call on their primary physicians
to discuss the needs of the members and together we setup a plan and work togeth
er on the plan.
I've experienced setting up travel to another state for a member to see a specia
list or researching the best homecare, therapy, extended facilities or working w
ith the social workers to set up longterm care. I work cohesively with the physi
cians, the nurses in the facilities, therapists, Physician's assistants and spec
ialist as a team for each patient because we want to obtain the best outcome.
In my history I have work and spoken with people and these teams all over the co
untry, and it is the job of the Case Manager to build this team and bring them t
ogether in behalf of the patient. I get a since of gratification when this happe
ns and we have done our job and helped someone that needed us.

As a Case Manager, I also assist in making sure that the care that's needed is c
ost effective by using my experience as a Utilization Review Nurse to determine
if the treatment and specialty meets the UR standards and criteria, and I also d
iscuss these cases with the Medical Directors.
I have been a Nurse Auditor for manage care companies such as Blue Cross Blue Sh
ield, Review Works, Great Lakes Health Plan ,and HEDIS for multiple companies. I
thoroughly enjoy the work of fact finding, details and discovery. I would docum
ent and summarize the findings and send them to the Medical Directors. Hedis is
done for NCQA to measure the performance on important dimensions of care and ser
vices.
I feel that I would be an asset to any HealthCare Management Company.

Career Highlights:
Karmonas Cancer Institute of Michigan
I initiated and put in place a process for Karmonas outpatient ambulatory clinic
s to move more efficiently and effectively in identifying the needs of patients
and complete the referral process for the patients by moving them expeditiously
to the next level of care and met with the team in each clinic to train and expl
ained the process to them. I monitored the process until the staff became effici
ent in applying the process. I was given accolades for this protocol in the form
of a letter of recommendation.
As a case manager I also pull and review charts for medical necessity in medica
l records for retro reviews to assist with Appeals or Retro Authorizations.
BCBS Recovery Department- worked Contingent as a RN Review Specialist
Worked with Medical Directors, Attorneys and the Field RN Reviewers that have bo
xes of charts sent to the department I worked in to continue the Audit of the me
dical information and set the amount owe from services not bill correctly or not
documented. If services documented or not documented did not match the billing
I assisted in recovering the amount over paid by comparing the amount to the set
schedule fee table for the state where services were rendered.
I would set up meetings for the providers and their attorneys to come in with th
eir documentation and meet with our Medical Directors and the company Attorneys
as well as with myself and the Field RN Review Specialist.
After reviewing all documentation and explanations we would either come to an ag
reement or proceed to court to pursue monetary recovery. Very enlightening exper
ience!
I have a very strong history with telephonic case management and utilization rev
iew with the State of Michigan for Medicaid Manage Care. I was trained to follow
state guidelines with Interqual and Millman and Roberts.
Traveler's RN Telephonic Worker's Compensation Case Manager
Sent to Florida for a week in the Traveler's Building for training.
It was good coverage of WC procedures, state laws.
Training consists of practices in individual teams on how to handle cases. Each
team given dummy cases with scenario's to answer questions and do a presentatio
n.
We had excellent trainers and I enjoyed the training it was very thorough, they
made it comfortable and it was easy to follow, it was as though it was second n
ature to them, and we learn and covered quite a bit.
Training for applications use for WC calls and documentation were done in a com
puter classroom.
This training made me a good WC Case Manager.
Michigan Peer Review Organization works directly with the State of Michigan.
I did telephonic Utilization Review with strict criteria. Set up case meetings f
or the Medical Directors with the providers that either wanted discussion on cas
es or challenged the MD's decisions.
I researched the cases to provide information of medical criteria for the Medica
l Directors.
I reviewed charts for information that did or did not meet criteria and discuss
ed the case criteria with the medical directors and provided a written summary.
I retro reviewed charts for Appeals and sent Decision and Determination letters
to the providers.
I have been a Psychiatric Nurse for Northville State Hospital, Michigan Osteopat
hic Medical Center and a Psychiatric Field Nurse Case Manager for the county of
Oakland.
I have been a Supervisor, Assistant Director and a Director of Nursing in skill
care facilities and managed up to a 100 personnel.