1. Darlene Cook
Spokane, WA 99205
darlene.cook824@gmail.com
(208)661-5829
• 19+ years of experience in the medical industry • Quantitative and Qualitative data analysis;
Special projects; project management; concurrent review; post payment review; provider
disputes; utilization management; workflow; market place • Family nurse experience • Coding
experience, ICD-9 ICD-10. CMS • Medicaid/Medicare charting experience • NCQA compliant
• HIPPA compliant • Psychiatric, Long-term care, and Sub-acute care HEIDIS QNXT; PDR
QA QIA Skills Billing, coding, authorizations, denials, disputes (10+ years)
Willing to relocate: Anywhere
Desired Job Type: Full-time Authorized to work in the US for any employer
Work Experience :
**Utilization Review Specialist--Medical claims review utilization mgt. QA cost savings
Molina Healthcare - Spokane, WA
Responsibilities during our "building" phase I did many different positions while the company
was trying to get off the ground in WA. Very little to no supervision. I took care of OH ER
claims, I am main corporate contact for IL, I have done provider disputes, coding, medical
claims review for CA. HEDIS, QNXT, PDR, QA I have also saved the company at least 3 million
dollars in reviews, UM, prior auth, incorrect coding and double billing for market place, Medicare
and Medicaid, among many other odd jobs to help out.
Experience with variety of states and claim types;(OH, IL, CA, WA, MI, UT, NM) SNF, LTC,
inpatient, outpatient, ER, office visits, med surge, behavioral health, transportation, high dollar
claim, prior authorizations, and ICU/CCU
Skills Used All of my monthly reviews were in the "wow" zone. I have exceeded my set daily
quota by double of what they expected. I have a good working relationship with all of our
medical directors in many states.
**LPN Unit Supervisor Eastern State Hospital - Medical Lake, WA September 2012 to
February 2013
Performed audits on medical records to ensure insurance coverage • Used ICD-9 Codes for
all labs and procedures to ensure proper payment • Medicaid charting • Coordinated Quality
Improvement Activities (QIA's) • Directs and supervises the professional nursing staff and
auxiliary personnel engaged in rendering patient care in various assigned psychiatric units;
prepares work schedules, makes assignments and supervises activities and evaluates work
performance • Coordinates services rendered with those of other departments; checks each
unit to assure compliance with instructions • Checks assigned personnel on units supervised;
prepares and reviews related time and work performance reports and makes changes in

2. personnel assignments as required or as directed by superior • Personally makes periodic
routine ward visits; confers with head nurses and staff nurses concerning all new patients;
makes visits to all seriously ill psychiatric patients; discusses specific problems with assigned
nurses or physician specialists • Administer medications • Monitor side effects and
recommend changes to Doctors if needed • Trained and applied Suicide watch on patients •
Trained on De-escalation techniques and conflict resolution
**Post Deployment Health Re-assessment Nurse Fairchild Air Force Base - Fairchild, WA
December 2010 to September 2012
Used ICD-9 Codes for all labs and procedures to ensure proper payment • Medicaid charting
• Coordinated Quality Improvement Activities (QIA's) • Ran the PDHRA program • Ensures
all members complete their post deployment requirements • Assessed member concerns and
book their appointments based on priority of need • Educated patients on all concerns both
physical and mental from work place to home life • Did mental health and physical health
assessments and made proper referrals
**Charge Nurse Extend A Care Corporation January 2009 to January 2011
Used ICD-9 Codes for all labs and procedures to ensure proper payment • Medicaid charting
• Coordinated Quality Improvement Activities (QIA's) • Long term and sub-acute care up to
24-36 patients at one time • Run a medication cart, Medicare charting and wound care •
Assist getting patient ready for physical therapy • Worked with wound-vacs, picc lines, and
central lines • Administered IV therapy
Education
North Idaho College - Coeur d'Alene, ID 2008
BSN in Psychology Lewis and Clark State College