Aleta R. Harris is applying for a position as a Nurse Consultant with the Food and Drug Administration. She has over 18 years of experience as a Registered Nurse and 15 years of experience as a Nurse Consultant in case management and education roles. Her experience includes work as a case manager, utilization manager, and team leader with various healthcare organizations. She believes her qualifications in areas like Medicare regulations, case management, and quality improvement would make her well-suited for the Nurse Consultant position.

1. Aleta R. Harris MSA, BSN, RN, CPHM
 240-535-5765  Counterclockwise56@gmail.com  8140 Tamar Drive  Columbia, Maryland 21045
Dear Human Resources Manager:
I would like to express my sincere interest in being considered for the position of Nurse Consultant. I
strongly believe that my experience and qualifications would be great assets; satisfying the mission and
goals of the Food and Drug Administration. Enclosed is a copy of my resume for your review and
consideration.
Of probable interest to you, is the fact that I possess vast knowledge and experience as a nurse
consultant. My career in nursing has provided me with exposure to various aspects of healthcare,
fostering astuteness in the application of quality healthcare principles, teaching methodologies,
efficiency and profitability within the health insurance arena.
Currently, I am employed as a Registered Nurse (RN) Case Manager with Johns Hopkins Healthcare
(JHHC) in Glen Burnie, Maryland. Through my experience, I provide ongoing consultative nursing
services and coordination of care for a special needs population of Medicaid enrolled members
throughout the eastern region; along with a reviewing and planning services for certain government
members within, the contracted federal plan through (JHHC). Further, my experience as a Utilization
Manager, Case Manager and Team Leader has afforded me the opportunity to become well versed with
interpreting and applying federal regulations, health insurance, and Health Management Guidelines,
affecting healthcare access, reimbursement and quality outcomes.
The following are additional highlights of my healthcare experience and qualifications:
• More than 18 years of experience as a Registered Nurse
• Approximately 15 years as a Nurse Consultant through case management and education roles
• 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 standards
• Leadership ability as both an administrative manager and a clinical team leader
• Case Management and Utilization Review experience
• Extensive training with Milliman 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
I am a self-motivated individual; possessing strong interpersonal skills with the ability to readily adapt
to the most challenging situations. Please evaluate my strengths and expertise, as I would appreciate
further discussion on how I might contribute to seamless quality as a Nurse Consultant with the Food
and Drug Administration.
Sincerely,

2. Aleta R. Harris RN, BSN, MSA, CPHM
Aleta R. Harris MSA, BSN, RN, CPHM
 240-535-5765  Counterclockwise56@gmail.com  8140 Tamar Drive  Columbia, Maryland 21045
 NURSE CONSULTANT 
Highly accomplished, Hardworking, self-motivated, proactive, and patient-driven professional nurse with
astute, comprehensive knowledge of Federal Regulations, Medicare guidelines, Insurance Regulations, education, and
nursing processes. Proven ability to provide critical thinking skills essential for providing competent and dignified patient
care. Positive interpersonal skills with a servant leader attitude; interface effectively with patients, families, and
colleagues. Flexible and adapt easily to changing environment and work schedule. Recognized for professionalism,
commitment to excellence, and ability to effectively cultivate meaningful relationships. Hold national certification in
Utilization Review Nursing and Nursing Case Management. Experienced with hospice care, home health, inpatient,
OBGYN, patient education, reimbursement, insurance authorizations, denial management and leadership.
CORE COMPETENCIES
Comprehensive Assessments Insurance Regulations Quality Improvement Policy Analysis
Admission and Discharge CMS Guidelines Appeals / Denials Management Relationship Cultivation
Patient-Centered Care Microsoft Office Programs Computerized Documentation Clinical Care Analysis
Medical Record Maintenance Leadership Data Collection
AREAS OF EXPERTISE
 Interpersonally adept; readily establishing rapport and sense of trust with diverse clients of various ages,
cultures, and socio-economic backgrounds, as well as with peers, physicians and support personnel.
 Comfortable in fast-paced situations and adept in managing time, prioritizing tasks, and exercising the sound
judgment required to improve the quality of patient care.
 Proficient in medical terminology, medical processes and use of medical equipment. As member of the medical
team, strive to provide continuum of best possible care, keeping needs of patients foremost in mind.
 Noteworthy computer and administrative skills. Flexible to changing priorities. Able to quickly identify and resolve
problems using available resources.
PROFESSIONAL EXPERIENCE
Johns Hopkins Healthcare, LLC Glen Burnie, Maryland
Case Manager RN (floater) October 2014 to Current
Coordinate care delivery and complete member healthcare needs assessments, based on physical and
psychological factors; conducting retrospective insurance and continued stay reviews, along with discharge
planning to ensure professional service and the proper utilization of resources across the entire care continuum.
Analyze, Interpret and apply Centers for Medicare laws and guidelines for admission and observation stays;
ensuring adequate documentation for payment of services. Remain abreast of new laws affecting Medicare and
reimbursement by researching legislation and policy updates. Cultivate new relationships with internal and
external customers; employing effective communication and collaborative efforts with community-based
organizations, while providing consultation for identifying services best aligned with members’ needs. Efforts
support local and corporate goals for membership growth. Identify potential medical service delays by
educating hospital staff and assisting them with identifying appropriate utilization services. Remain abreast of
new laws affecting Medicare and reimbursement by researching legislation and policy updates. Analyze,
Interpret and apply Centers for Medicare guidelines for admission and observation stays; ensuring adequate
documentation for payment of services. Effectively interface with nursing leadership, team leader and
physician for communicating delivery of case management services, services pending, case approvals and
denials outlined in company policy. Track and trend data, providing reports necessary for identifying and
improving quality issues related to authorizations and denials management. Provide support to the Appeals
Management Practice; reviewing medical records and preparing professional, effective clinical appeals in
response to medical necessity denials managed care and DRG reassignments, governmental and Recovery Audit
Contractors (RAC) denials for hospital clients. Successful appeals have consistently resulted in overturning
denied claims and recovering revenue for our clients. Collaborate with nursing leadership and colleagues when
leading activities for scheduling and facilitating team meetings, setting agendas, managing and disseminating

3. information, establishing project timelines; delegating team assignments; adhering to deadlines and providing
regular reports and project updates to upper management.
United HealthCare
XLHealth/Care Improvement Plus Baltimore, Maryland
Utilization Management Coordinator September2013-Current
Provided nurse consultative services through education and coordination of utilization operations assigned
within the Medicare plan and Medicare management team, while implanting intergovernmental Federal
regulatory policies. Collaborated with insurance contract specialists for ensuring compliance through applying
guidelines for various Medicare products within the Medicare Advantage plan operations. Interpreted and
applied policies for ensuring program success. Communicated any changes in patient Model of Care to the
Medicare management, and plan interdisciplinary team Coordinated implementation of interdepartmental
processes (policies and procedures) related to Medicare business Completed Transfer of Care Risk Assessment
for Medicare Advantage Plan members and collection of Medicare Revenue. Participated in medical cost
discussions and evaluate the Member Discharge plan to decrease costs. Reviewed 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.
Prepared denial letters and NOMNC letters for the plan.
Mercy Medical Baltimore, Maryland
Case Manager RN (floater) May 2013- October 2013
(Temp Employee-Contract)
Coordinated delivery and member health care needs through conducting comprehensive nursing assessments,
based on physical and psychological factors. Conducted 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. Provided support to the Appeals Management Practice; reviewing medical
records and preparing clinical appeals in response to medical necessity denials and DRG reassignments.
Successful in overturning denied claims and recovering revenue for our clients by writing professional, effective
clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.
National Institutes of Health Bethesda, Maryland
RN-Clinical Research Nurse II September 2012-May 2013
Worked in the Clinical Monitoring Research Program (CMRP), and was responsible for providing clinical
research and 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.
Supported 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. Collected and analyzed patient data,
provided assistance and managed patients through use of program databases. Applied knowledge and training
of protocol-specific regulations and functioning according to the provisions of approved investigational
protocols. Performed a wide range of duties associated with a protocol’s life cycle from development through
termination, with particular attention to writing manuscripts and protocols. Ensured 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.

4. Amerigroup Community Care Hanover, Maryland
RN- Quality Coordinator October 2011-September2012
Designed and implemented quality improvement studies, including selecting valid and reliable indicators for
monitoring and evaluating activities. Created and maintained ongoing quality database system; facilitating and
attending corporate and departmental committee meetings and workgroups. Assisted with the planning and
execution of health promotions outreach team, for which yearly initiatives to meet annual goals for Medicare
Stars and Value-based purchasing (Medicaid) HEDIS measures were established. Analyzed, tracked, and
trended data; preparing concise, accurate and meaningful quality management reports in accordance with
Company procedures for improving quality. Actively participated in intradepartmental quality management
improvement teams; coordinating resolution of high level complaints; educating AMERIGROUP associates
about the QM process; Assisting in defining opportunities for improvement through analysis of trends; assisting
with preparations for the Quality Improvement Council and other QM related Corporate and Maryland Plan
committee meetings; implementing, analyzing and evaluating the Company-wide inter-rater reliability program;
assisting various departments with preparation for NCQA and Delmarva Accreditation; maintaining quality
management documents, case files and correspondence in an organized, confidential and secure manner;
conducting, as appropriate, oversight audits for all nationally delegated vendors; developing and maintaining
vendor audit tools; communicating significant findings, including potential risk management issues to the AVP
of Quality Management; assisting with coordinating HEDIS Improvement Activities; assisting with
coordinating Member and provider Satisfaction Improvement activities; assisting with Health
promotions/outreach clinic days; creating the quality management yearly work plan and the end of the year
program evaluation for Medicare; and presenting quarterly and semiannual quality reports along with NCQA
required analysis to corporate executives and department heads within various committees.
Mercy Medical Center Baltimore, Maryland
RN Case Manager December 2005-July 2009
Utilized the nursing process for assessing, implementing, and communicating care plan objectives for
individual patients to Mercy Hospital’s executive administrative team, while coordinating the identification
high-risk patient cases and collaborating regularly with physicians to assure patient access to quality, cost
effective health care. Interacted with other nursing staff.
Special Recognition: Was recognized for distinguished service by the Medical Director and tapped for
participation on the Maternal Child health Care Committee, an interdisciplinary group of doctors, social
workers, and nurses tasked to develop health education initiatives that supported state regulatory
objectives and requirements. Collected data and initiated QPM, graph data. Assisted with
implementation of GE system that would allow for more finite and quicker data collection. Committee
responsibilities included: contributing to the establishment of short and long term goals for
communicating care plan objectives to patients and their families in addition to identifying barriers to
obtaining insurance authorization for admission and continued stay from private insurance agencies, as
well as, agencies like Medicare and Medicaid.
CareFirst Blue Cross Blue Shield Washington, DC
RN -Clinical Care Coordinator August 2003-December 2005
Coordinated services for CareFirst Blue Cross Blue Shield, Hospital based healthcare plan; ensuring service
delivery and member health care needs assessments, based on physical and psychological factors; pre-certs;
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. Minimized hospitals costs
by identifying potential medical service delays that might have resulted in denials. Assisted hospital staff with
identifying appropriate patient resources for accessing appropriate levels of care for patients. Interpreted and
applied contractual guidelines for companies seeking insurance prior authorizations with active policy
modification and analysis.

5. Mid-Atlantic Medical Services, Inc. (Mamsi) Rockville, Maryland
RN- Utilization Review Nurse November 2001-August 2003
Conducted comprehensive utilization review assessments of inpatient cases against Mid-Atlantic Medical
Services’ benefit system and provided cost benefit analysis for member care criteria. Facilitated cost
containment and provided evaluation on members’ treatment based on medical, mental health, and substance
abuse service cost constructs. Provided concurrent and retrospective care reviews to ensure the proper
utilization of resources across the care continuum, while proactively collaborating with hospital staff to identify
appropriate services utilization.
Healthcare Strategies, Inc. Columbia, Maryland
RN- Education Counselor and Care Coordinator May 2000-November 2001
Provided consultation and medical reviews for more than 200 insurance companies in maternity, medical-
surgical-oncology and psychiatric nursing, drawing from extensive experience as a registered nurse; conducting
maternity screening interviews and providing insured clients with medical advice and referrals via a nursing
hotline; identifying physical and psychological characteristics of the symptoms and illnesses described by
patients; and accurately preparing recommendations and referrals in order to get approval for outpatient/
inpatient surgeries and hospital stays. Assessed patient learning needs, providing education and guidance to
patients and staff for outlining clinical outcomes for improving healthcare.
McGuire Veterans Affairs Medical Center Richmond, Virginia
RN-Charge Nurse/Team Leader September 1998-May 2000
Provided leadership, supervision, and oversight of clinical practice of nursing staff on a 40 bed, medical-
surgical-oncology unit. Effectively utilized staffing and overtime resources; assigning nursing hours based on
knowledge, skill, ability and patient acuity. Conducted quality chart reviews, ensuring presence of adequate and
accurate clinical documentation. Utilized the nursing process; assessing patient care needs, administering
pharmacological intervention, and revising nursing policies affecting care and outcomes. Conceived and
implemented hospital-wide, quality improvement initiative, “Identifying Best Practices” (for the treatment of
high-risk patients); directing the unit’s patient education program, while serving as the primary liaison for cross-
functional engagement between the medical- oncology unit and other units within the medical center.
EDUCATION
Master of Science: Health Administration  Central Michigan University  Mount Pleasant, Michigan May 2004d
Bachelor of Science: Nursing  North Carolina Agricultural and Technical State University  Greensboro, NC May 1997
TRAININGS
ICD-9 & ICD-10; CPT CODES
Interqual Criteria 2014 & 2015
Milliman Care Guidelines
LICENSES AND CERTIFICATIONS
Registered Nurse-- State of Maryland
Basic Life Support (BLS) for Health Providers
CPHM Certified (CPUM and CPUR combined)
VOLUNTEER AFFILIATIONS
Delta Sigma Theta Sorority, Incorporated
Chapel of Restoration Food Bank
AFFILIATIONS
Chi Eta Phi, Nursing Sorority, Inc.
Delta Sigma Theta Sorority, Inc., Member
(Community Service Committee and Health Outreach Committee)
American Association of Managed Care Nurses, Member
References
Available Upon Request