Experience

Health Integrated, Inc.

• United States
• Medical Practices

• UM Review Nurse

  • Oct 2011 - Present

  I provide acute in-patient utilization management for LA hospitals. I use Interqual and Milliaman criteria daily. I previously worked on the Affinity Health plan / New York hospital Inpatient/outpatient utilization review. I have trained the new employees on both inpatient and outpatient UM review. Time management, TAT compliance and Case Management referral notification of case load is priority at all times. Health plan knowledge, constant communication with MD’s / Case Managers and adaptability is a must. Understanding of policy and procedure is the back bone to successful reviews. I strive to meet TAT while maintaining quality work. Show less



CareCentrix

• United States
• Hospitals and Health Care
• 700 & Above Employee

• UM Review Nurse

  • Oct 2010 - Aug 2012

  I was a Licensed Utilization Management Reviewer in the Triage Department at Care Centix. I processed provider requests for HME and THH services. Functioning as a third party administrator for many health plans I strive to meet (TAT) turnaround time for each case/plan. I have profound knowledge of several insurance health plans such as Centene, Wellcare, Cigna, VSHP and BlueCross BlueShield (Florida Blue). I utilized the tools and resources of insurance policies criteria while following UM guidelines. I also determined if a referral required additional review by the health plan. One of my main responsibilities is completion of the RFD elevation documentation and processes. I also processed reauthorizations. Understanding the computer system, changing health plans, HCPC and ICD9 codes are all essential for day to day work. I have an understanding of how to navigate the DMAC/CMS government hierarchy system. Utilizing Windows, Outlook, and other necessary computer programs was required daily. Show less



Shriners Hospitals for Children

• United States
• Retail Apparel and Fashion

• LPN Floor and Clinic Nurse

  • Jun 1992 - Dec 2010

  I worked on all three in-patient units, out-patient, and same-day surgery. The majority of that time I worked on the infant and toddler in-patient unit. I have experience with pediatric specialties such as: urology, neurology, neuro-surgery, plastic surgery, spine care, and hand surgery. Cerebral Palsy and Myelodysplasia were the majority of our patient clientele. I have 3 years of experience in the out-patient clinic. This was a multidisciplinary clinic offering on-site services such as orthotics and prosthetics, all specialists listed above, therapy, and custom wheelchairs. I have been fortunate enough to gain experience in rare diagnosis such as Osteogenesis Imperfecta, many rare syndromes and cutting edge orthopedic care. Show less