Shirley Nelson, RN Resume

1. Shirley Nelson RN
Mobile Phone: 949-370-2395
E-mail: shirleyrnelson@hotmail.com
OBJECTIVE
To improve the quality of care and service provided within a healthcare organization by applying
expertise in Utilization Management and Quality Management.
WORK EXPERIENCE
Director of Utilization Management and Quality Improvement
February 2007 - March 2010
CareMore Medical Enterprises | Cerritos, CA
Healthcare Services
Directed Utilization Management (UM) and Quality Improvement (QI) operations for Medicare
Advantage and Special Needs Plan health plan and staff model medical group. Encompassed
staff of fifty professional and administrative staff, including 5 unit managers who were direct
reports. Conducted employee hiring, coaching, counseling and mentoring functions. Maximized
employee satisfaction and retention through training and teamwork. Prepared clinical department
programs, work plans, policies and procedures meeting all CMS standards. Conducted mock
audits to ensure CMS audit readiness. Directed committee functions for UM/QI, Credentialing
and PCP Advisory Group. Implemented UM/QI assessment and monitoring tools for regional
markets. Conducted extensive UM/QI process and system training. Built collaborative regional
market relationships through multidisciplinary forums which included General Managers,
Medical Directors, Vice Presidents, Provider Relations and UM staff. Improved specialty referral
process by increasing automatic authorization rate and decreasing turn around time to process
referrals. This was accomplished through the development of UM metric reports and the
ongoing monitoring of the metrics. Interim director for case management department 1.5 of 3
years. Implemented online Case Management program to improve identification, documentation
and management of case management enrollees. Reduced ER visits, hospital admits, readmits
and length of stay. Streamlined Credentialing process by implementing national on-line
application process. Maximized HEDIS scores through provider/member education and
performance feedback process. Completed NCQA Special Needs Plan structure, process and
outcome project. Improved provider satisfaction and member satisfaction by identifying areas of
opportunity and implementing network interventions.
QI/Credentialing Manager
September 2001 - November 2005

2. Physician Weblink of California | Irvine, CA
Healthcare Services
Managed daily operations of QI division including appeals, grievances, credentialing and
denials. Secured NCQA Certification in Credentialing/ Recredentialing. Directed all clinical
compliance activities. Developed robust interventions for Pay for Performance measures,
resulting in increased compensation to organization. Achieved and maintained full delegation
status for utilization management, case management and credentialing. Interim manager for
hospitalist program, case management and inpatient services. Reduced hospital admits, readmits
and length of stay.
QI Nurse Specialist
November 2000 - September 2001
Sharp Health Plan | San Diego, CA
Healthcare Services
Managed clinical regulatory requirements. Directed NCQA and HEDIS projects including
HEDIS data collection activities, Baseline Assessment Tool completion and validation, data
submission to NCQA and onsite audit functions. Designed QI/UM delegation oversight tools.
Completed Quality Improvement studies. Conducted member grievance and appeals reviews.
Director of Clinical Operations
August 1988 - March 1999
PacifiCare Health Systems | Cypress, CA
Healthcare Services
Directed quality management, utilization management, credentialing and case management units.
Key contributor in all NCQA, CMS and DMHC activities. Assisted PacifiCare of California,
Oregon, Washington, Texas, Oklahoma and Florida with NCQA readiness and survey process.
Facilitated member and employee transition of one million member health plan. Developed
Quality Networking provider education program. Implemented medical group transition process
to retain members.During eleven year tenure held multiple QI positions with increasing scope
and responsibility from QI Specialist to QI Manager to Clinical Operations Director level
positions.
QI/UM Manager
July 1987 - July 1988

3. Sharp Memorial Hospital | San Diego, CA
Healthcare Services
Managed and integrated quality management, infection control, utilization management and
discharge planning staff and functions. Collaborated and coordinated services with Primary Care
Nurse Case Management Program. Reduced average length of stay from 13.0 days to 5.5 days
through creative discharge planning and coordinating community and organizational services.
Successful completion of JCAHO survey.
EDUCATION
Bachelor's Degree,
9 1976 - 5 1980
Augustana College | Sioux Falls, SD
Bachelor's Degree In Nursing
Registered Nurse State of California
LANGUAGES
English Fluent