Shamika Thomas, RN

Registered Nurse with a vast amount of clinical experience in case management, quality assurance, transition of care, utilization management, HEDIS, home health, bedside nursing, end of life as well as chronic disease management and education. Proficient and effective multi-tasker with expert level computer and technology skills including use of smart phone and iPad.

Jersey College School of Nursing, Sunrise, FL 11/2019-11/2021
Associates Degree in Nursing

Multi-State Compact Registered Nurse
Multi-State Compact Licensed Practical Nurse

• Collaborate with provider with establishing patient treatment plan.
• Monitor and report any changes in patient symptoms
• Facilitate referrals to other healthcare professionals and medical facilities.
• Provide emotional support to patients and their family
• Identify community resources which may be beneficial to patient.

• Review clinical documentation submitted for appropriateness of service or durable medical equipment being requested.
• Utilize CMS criteria to make recommendations on requested services for Medicare members
• Utilize ACHA guidelines to determine appropriateness for services being requested for Medicaid members.
• Follow-up with various line of business regarding status of outstanding request.
• Liaison with Medical Directors regarding complex cases.

• Review medical records and documents to abstract clinical data for HEDIS reporting.
• Integrating collected electronic data into reports
• Meeting daily abstraction goals and maintaining abstraction accuracy
• Outreaching members to obtain missing data information
• Maintaining HIPPA standards while working in a remote environment.

• Review clinical documentation submitted for appropriateness of outpatient, Inpatient, and DME services being requested while meeting daily required quotas.
• Reviewed request for appropriate ICD 10 codes
• Process authorization request for Medicaid and Medicare members within allotted turnaround time using InterQual as well as company policies and procedures.
• Abstract HEDIS measures and submit to Quality Assurance Department.
• Liaison with Medical Directors regarding complex cases.

• Evaluate Medicaid CMS members for case management services and determines appropriate level of care coordination.
• Complete comprehensive assessment and develop care plans based off of member’s needs.
• Develop and monitor member’s plan of care identifying progress towards meeting goals
• Routine interaction with member and caregiver assessing for additional needs/resources
• Liaison and member advocate between the member and parent with the physician and facilities/agencies
• Assess the options for care including use of benefits and community resources.

• Manage care panel of 350+ patients with chronic conditions including but not limited to: Diabetes, CHF, Hypertension, Cancer and COPD for two primary care practices.
• Coordination of care for Medicaid, Medicare and commercial plan patients
• Review patient’s chart to ensure required HEDIS screenings are completed
• Abstract HEDIS measures from medical records and upload to BlueCross BlueShield database
• Outreach patients for disease process education and teaching both telephonically and in the office.
• Meet with primary care provider daily to identify patients who require additional case management for both health related and social determinate complications
• Coordinate translation of care for patients admitted to hospital, ensuring all post hospitalization services are set up and conduct weekly follow up phone calls to reduce risk for readmission.
• Coordinate care for medically complex patients who require specialist and interdisciplinary team approach.
• Conduct monthly case staffing meetings with providers and office staff to review and discuss both medically complex and high-cost patients.

Review clinical documentation for Molina Medicaid members for inpatient medical necessity on an initial and concurrent review basis. Process authorization request for initial and concurrent review for inpatient stay using InterQual, Milliman and company policies. Coordinate facility transfers as needed for members requiring continued medical treatment at SNF or Long-Term Acute Care facilities. Consult with and refer cases to Medical Director which do not meet criteria as needed. Discharge plan with Transition of Care team to ensure member has scheduled OP follow-up appointments, DME equipment and home health care to reduce readmission. Refer member to additional plan programs i.e., High Risk OB, Oncology Team, and Community Connectors for members with HIV & Sickle Cell.

Review clinical documentation submitted for Sunshine Medicaid and Medicare members for appropriateness of services being requested. Process authorization request for Medicaid and Medicare members within allotted turnaround time using InterQual as well as company policies and procedures. Assist with the resolution of escalated authorization request and ACHA complaints. Clinical preceptor as well as member of department performance improvement committee. Member of HEDIS team during HEDIS season.

Furnished upon request