Experience

Health Partners Plans

• United States
• Hospitals and Health Care
• 300 - 400 Employee

• Utilization Review Nurse

  • Mar 2015 - Present

  Health Partners Plans is an award-winning, not-for-profit health maintenance organization serving more than 263,200 members in Philadelphia, Chester, Delaware, Bucks and Montgomery counties.Work to assure cost effective, quality utilization management in the acute/post acute level of care setting. Review clinical information provided by facilities and communicate UM determinations maintaining timeliness. • Review and track emergency admissions to identify appropriate level of care. • Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines. • Track assigned cases for timely reviews/updates and decisions as reflected in case documentation. • Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision. • Function as a liaison between providers, members and interdepartmentally. • Serve as resource for physicians, PCPs, Utilization Review departments and all medical providers. • Identify trends that impact on utilization at hospitals during the review process and help resolve them. • Maintain departmental and regulatory timeframes for utilization decisions. • Contributes to the development and enhancement of documentation, tracking tools and process flows. • Maintains collaborative and effective cross- functional training within the Utilzation Management Department Utilzation management perform after hours on-call coverage. • Participates in relevant work groups and provide deliverables as necessary. • Successful and timely completion of assignments in accordance with departmental and Company operational objectives and seeks feedback on performance. Ensures that assignements are scheduled and completed in an accurate and timely manner. • Maintains detailed knowledge of the status of all assignments and routinely updates the manager, as appropriate. • Performs all other duties as assigned.



Cigna Healthsprings

• Utilization Review Nurse

  • Sep 2014 - Mar 2015



Immaculate Mary Home

• Utilization Review Nurse

  • Mar 2008 - Sep 2014

  Immaculate Mary Home is a Catholic, non-profit skilled nursing facility in Northeast Philadelphia. The home is owned and operated by the Archdiocese of Philadelphia. As the Utilization Review Nurse, my responsibilities include, but are not limited to:* comprehensive medical record review of a resident's admission or readmission into the facility.* monitoring residents' conditon and health care insurance payor information daily and ensuring that the resident is receiving the appropriate level of care.* communicating to managed care insurance companies regarding a resident's progress in therapy and physical condition in order to continue certification of skilled level of care for the resident. * Screening potential candidates for admission and determining if their needs can be accomodated by the facility.* Monitoring residents' condition daily while they are in alternate healthcare settings and coordinating their readmission back into the facility.* Bridging the gap between various departments in the facility in order to aid in ensuring the continuity of care.* Participation in nursing staff education regarding appropriate documentation of skilled nursing services.* Statistical analysis and auditing of nursing documentation, as well as overall facility performance in various clinical aspects.



Nazareth Hospital

• Registered nurse Case Manager

  • 1991 - 2003