I currently work as a Registered Nurse (RN) in the Utilization Management Department at Johns Hopkins Healthcare. The following are additional highlights of my healthcare experience and qualifications: After reviewing my resume, it will be quite evident that my experience has provided me with exposure to varied aspects of healthcare, while also teaching me the importance of quality, efficiency and profitability within the insurance arena. Further, my past experience as a Utilization Review (UR) nurse, case manager and team leader gives me the desired edge over other candidates, as I have already been exposed to many UR Guidelines and industry resources. I would welcome a personal interview at your earliest convenience, to discuss your objectives and to get more information about the position. Please feel free to contact me at 240-535-5765 (Cellular). Thank you, in advance, for your kind consideration of my interest and qualifications. Specialties: More than 14 years of nursing experience as an RN • More than 14 years of nursing experience as an RN • Completion of a Master’s Degree in Health Services Administration (May 2004) • Medicare Advantage Plan Knowledge- Denials (NOMNC Letters) and Medicare Stars • MCO Medicaid Plan knowledge – Value Based Purchasing • Medicare RAC Appeals ( QIO and ALJ levels) • Strong resource with the credentialing process of Delmarva and NCQA accreditation • Leadership ability as both an administrative manager and a clinical team leader • Case Management and Utilization Review experience • Extensive training with MCG and InterQual guidelines • CPHM certification (CPUM and CPUR are now combined) • Strong knowledge of writing and implementing Quality Management Policies and Procedures • Project Management with Executive Senior Management and Department Heads • Facilitating and attending corporate and departmental committees meetings • HEDIS training and experience

RN Care Coordinator @ From October 2014 to Present (1 year 3 months) Utilization Management Coordinator (CIP/Medicare) @ Coordinate operations assigned within the plan Medicare management team and implanting intergovernmental Federal regulatory policies related to various Medicare products within the Medicare Advantage plan operations to ensure compliance. Communicate any changes in patient Model of Care to the Medicare management, and plan interdisciplinary team Coordinate implementation of interdepartmental processes (policies and procedures) related to Medicare business Complete Transfer of Care Risk Assessment for Medicare Advantage Plan members and collection of Medicare Revenue. Participate in medical cost discussions and evaluate the Member Discharge plan to decrease costs. Review the individual Medicare programs to improve and manage benefit delivery Interprets Centers for Medicare and Medicaid Services (CMS) regulations for Skilled nursing (SNF) and Long-term Care facilities (LTAC) with member placement .Prepare denials letter and NOMNC letters for the plan From September 2013 to October 2014 (1 year 2 months) Case Manager- part time/ per diem @ Coordinating delivery and member health care needs assessments, based on physical and psychological factors; conducting retrospective and continued stay reviews, along with discharge planning to ensure professional service and the proper utilization of resources across the entire care continuum; improving collaborative relationships with community-based organizations, while providing direction in identifying those that best meet the needs of members and support local and corporate goals for membership growth; and identifying potential medical service delays by helping hospital staff to identify appropriate services utilization. Provide support to the Appeals Management Practice. Reviews medical records and prepares clinical appeals in response to medical necessity denials and DRG reassignments. Successful appeals will result in overturning denied claims and recovering revenue for our clients. Responsibilities: Prepared professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients. From May 2013 to September 2013 (5 months) Clinical Trials Case Manager @ The Clinical Monitoring Research Program (CMRP) is responsible for providing clinical research nursing support to the National Institutes of Health’s (NIH) Division of Research Development with the NIH Clinical Center, specifically supporting the Interventional Radiology Research Program. The Clinical Research Nurse II supports the research team in providing therapies that use imaging technology to diagnose and treat localized cancers in ways that are precisely targeted and minimally or non-invasive. Provided assistance and managed patients and patient data through use of program databases, using the knowledge of protocol-specific regulations and functioning according to the provisions of approved investigational protocols. Performs a wide range of duties associated with a protocol’s life cycle from development through termination with particular attention to writing manuscripts and protocols. Ensures scientific quality and human subject’s protection, Recognizes and supports the needs of data integrity and retrieval, and interprets needs appropriately for principal investigators, patients and other staff members. This position is located in Bethesda, Maryland Facilitate and coordinates care for patients who have volunteered in the clinical trials protocols within the National Institute of allergy and Infectious Disease division. From September 2012 to May 2013 (9 months) Quality Management RN @ Responsible in conjunction with management for developing, coordinating, implementing, and evaluating the continuous quality improvement activities throughout the company according to the established Quality Management program. Establishes indicators for monitoring and evaluating the full spectrum of care and services provided to members for quality, appropriateness, continuous improvement and satisfaction. Provides education in the area of quality management to all departments and assists in ensuring compliance with regulatory and accrediting organizations. 1. Designs and implements quality improvement studies including selection of valid and reliable indicators and coordinates monitoring and evaluation activities 2. Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance with Company procedures. 3. Actively participates in intradepartmental quality management improvement committees as appointed. 4. Coordinates resolution of high level complaints. 5. Educates AMERIGROUP associates about the QM process. 6. Assists in defining opportunities for improvement identified through analysis of trends and communicates these appropriately. 7. Assists in the preparation for the Quality Improvement Council and other QM related committee meetings. 8. Implements, analyzes and evaluates the Company-wide inter-rater reliability program. 9. Responsible for maintaining quality management documents, case files and correspondence in an organized, confidential and secure manner. 10. Conducts, as appropriate, oversight audits for all nationally delegated vendors. 13. Develops and maintains ancillary vendor audit tools. 14. Communicates significant findings, including potential risk management issues to the VP Quality Management as indicated in a timely manner. 15. Assists with coordinating HEDIS Improvement Activities. 16. Assists with coordinating Member Satisfaction Improvement activities. From October 2011 to September 2012 (1 year) Utilization Manager @ Amerigroup Community Care Hanover, Maryland RN Utilization Manager July 2009-Current The Utilization manager is responsible for providing clinical supervision to a team responsible for coordinating member service, utilization, access, and concurrent review to ensure cost effective utilization of health, mental health, and substance abuse services. • Manages and oversees team responsible in case finding and coordinating those cases that involve comorbid conditions and need to be part of the case management/disease management track. • Manages and evaluates team's performance and ensure adherence to department's standards • Responsible for coordination and service delivery to include member assessment of physical and psychological factors. • Works with providers to establish short and long term goals that meet the member's need, functional abilities and referral sources requirements. • Communicates care plan objectives utilizing community resources to individuals, departments, and providers identified as having a role in the care of members. • Coordinates the identifications of members with potential for high risk complications. • Assesses members' present level of physical/mental impairment utilizing defined criteria and methodology. • Review benefit systems and cost benefit analysis. • Evaluates the member against level of care criteria. • Demonstrates knowledge of utilization management targets. • Acquires data and evaluates necessary medical, mental health and substance abuse service for cost containment. • Requests direction from Medical Director on complex healthcare issues. • Maintains member confidentiality and respect of the patient bill of rights. From July 2009 to July 2011 (2 years 1 month) RN Case Manager @ Currently employed part time ( Per Diem-on call ) Mercy Medical Center Baltimore, Maryland RN Case Manager December 2005-June 2009(full time) December 2005- current (part time) Currently performing and documenting appropriate admission and continued stay reviews. • Collaborating with physician to assure patient access to appropriate level of care • Assuring that patients and families have sufficient information to make informed decisions • Identifying barriers to quality, cost effective care, with the use of InterQual criteria • Obtaining insurance authorization for admission and continued stay with private insurance agencies and governmental agencies such as Medicare and Medicaid • Coordinating and participating in multidisciplinary rounds as required by JACHO • Coordinating and overseeing discharge plans • Identifying inefficiencies/opportunities for continuous quality improvement in a patient care • Serving a resource to healthcare team members • Participating as a member of the Pediatric Care Committee — an interdisciplinary group of doctors, social workers and nurses, which identifies and creates solutions for pediatric and NICU concerns From December 2005 to July 2009 (3 years 8 months) Utilization Review Nurse @ Carefirst Blue Cross Blue Shield Washington, DC Telephonic Clinical Care Coordinator August 2003-December 2005 Provided reviews related to the medical necessity of admissions, continued stay, and professional service to ensure appropriate utilization of resources across the entire care continuum. • Identified potential hospital service delays • Worked proactively with hospital staff to identify appropriate/inappropriate services utilization • Conducted retrospective care reviews • Reviewed cases for sub-acute placement • Identified patient needs with regard to discharge planning From August 2003 to December 2005 (2 years 5 months)

Master of Science (MS), Health and Medical Administrative Services @ Central Michigan University From 2001 to 2004 Bachelor of Science in Nursing, Nursing @ North Carolina Agricultural and Technical State University From 1991 to 1996 Aleta Harris is skilled in: Clinical Research, Case Management, Healthcare, Healthcare Management, Hospitals, Leadership, Managed Care, Management, Medicaid, Medicare, Nursing, Software Documentation, Utilization Management