Clinical Denials Nurse Team Lead

• Mar 2021 - Present

Utilization Management Nurse

• Apr 2018 - Mar 2021

Coordinate, document and communicate medical services and benefit determination Review and process inpatient hospital admission requests Follow established guidelines and procedures Interpret guidelines, policies and procedures to support the best treatment options Coordinate and communicate with providers to facilitate best patient care Maintain competency with organizational goals and objectives Refer appropriate cases to Medical Director for review Show less

Registered Nurse

• Sep 2015 - Apr 2018

Utilization Management-current role Review Inpatient and Outpatient Prior Authorization Requests Review and evaluate eligibility regarding benefits and covered services Use Nationally Recognized criteria and Internal policy criteria to determine medical necessity of services requested Refer provider requests appropriately to Medical Director when medical necessity is not met Serve as liaison between the Provider and the Medical Director Serve as as liaison between the Medical Director and External Review Consultants Case Manager Provide active case management services to enrolled members Review and evaluate eligibility regarding benefits and clinical standards Plan, coordinate, and monitor services to support members in managing their illnesses Provide telephonic support to members with chronic diseases and illnesses Perform medical reviews and prior authorizations Maintain up-to-date knowledge of contracts and network standing for all service providers Educate members on their benefits, chronic conditions, treatment plans and resources Serve as member supporter through communication and teaching Quality Improvement Coordinator-previous role Complete quality improvement activities and monitor and maintain compliance Analyze/Record/Present findings of quality improvement activities Advise corrective action and improvement when necessary Conduct quality medical record reviews to monitor quality of care and service provided Track and investigate quality issues and complaints Coordinate HEDIS document collection Coordinate with providers to identify and manage gaps in members care Show less

Clinical Documentation Specialist

• Jan 2015 - Sep 2015

Improve quality and completeness of clinical documentation Facilitate modifications to clinical documentation to ensure appropriate reimbursement Ensure accuracy and completeness of clinical information used for measuring and reporting outcomes Educate members of the patient care team Communicate and query physicians for clarification of clinical documentation Generate reports with information concerning Case Mix Index, physician query rates Improve quality and completeness of clinical documentation Facilitate modifications to clinical documentation to ensure appropriate reimbursement Ensure accuracy and completeness of clinical information used for measuring and reporting outcomes Educate members of the patient care team Communicate and query physicians for clarification of clinical documentation Generate reports with information concerning Case Mix Index, physician query rates

Case Manager I-Prior Authorization Nurse

• Apr 2013 - Jan 2015

Absolute Total Care Case Manager I-Prior Authorization Nurse Review Inpatient and Outpatient Prior Authorization Requests Provide customer service to Medicaid providers Utilize Nationally Recognized Criteria and Internal Policy criteria to determine medical necessity of services requested Assist with special projects to revamp internal policies Refer provider requests appropriately to Medical Director when medical necessity of services is not met Serve as a clinical resource to referral staff Serve as a liaison between the Provider and the Medical Director Enter authorization data into the system Train new employees Show less

Medical Reviewer II

• Oct 2011 - Apr 2013

Perform medical reviews using medical/clinical documentation Research Medicare policy and coverage data Document decisions using clinical guidelines Carry out appeals according to established guidelines Develop professional correspondence for providers and beneficiaries according established protocols Train new employees on the review process Perform medical reviews using medical/clinical documentation Research Medicare policy and coverage data Document decisions using clinical guidelines Carry out appeals according to established guidelines Develop professional correspondence for providers and beneficiaries according established protocols Train new employees on the review process

Registered Nurse

• Sep 2007 - Dec 2011

Assess patient status and notify physicians of clinical changes Care for medical and general surgery patients Provide various types of wound care Provide safe and excellent nursing care to all patients Organize care for up to seven patients Administer medications; oral, intramuscular and intravenous Perform clinical tasks according to hospital policy Admit and discharge patients Assist and educate patients/families on health care needs Monitor and maintain patient charts Precept new nurses Show less

Fitness Specialist

• Jul 2004 - Sep 2007

Orient and educate members on fitness equipment Assist members with workouts Provide personal training and education Maintain equipment Provide off-site health screenings Train new employees Orient and educate members on fitness equipment Assist members with workouts Provide personal training and education Maintain equipment Provide off-site health screenings Train new employees