Utilization Reviewer

• Jun 2016 - Present

• Conducts utilization reviews for admission and continued stay utilizing InterQual & MCG care guidelines. • Communicates with the physician advisors for a determination once a patient is not meeting criteria for admission or continued stay. • Coordinate care for patients after conducting assessments and devising a care plan based on their needs. • Conducts utilization reviews for admission and continued stay utilizing InterQual & MCG care guidelines. • Communicates with the physician advisors for a determination once a patient is not meeting criteria for admission or continued stay. • Coordinate care for patients after conducting assessments and devising a care plan based on their needs.

RN Case manager

• Nov 2005 - Present

Registered Nurse

• Feb 2004 - Dec 2005

• Provided ambulatory care and medication administration to patients in a maximum-security prison. • Supervised LPN’s and medical record technicians. • Provided ambulatory care and medication administration to patients in a maximum-security prison. • Supervised LPN’s and medical record technicians.

Case Manager Team Lead

• May 2004 - Nov 2005

• Coordinated the care and services for the Division of Youth and Family Services, pediatric and HIV population under the Medicaid contract with the state of New Jersey. • Supervised the department Program Coordinators and Social Service Specialists. • Coordinated the care and services for the Division of Youth and Family Services, pediatric and HIV population under the Medicaid contract with the state of New Jersey. • Supervised the department Program Coordinators and Social Service Specialists.

Supervising Registered Nurse

• May 2002 - Apr 2004

• Monitored and supervised the care of the mentally and developmentally disabled population in a group home setting of 15 residents. • Performed medication administration supervision of workers, reviewed medications ordered and coordinated medical care and follow-up treatment plans with their doctors. • Monitored and supervised the care of the mentally and developmentally disabled population in a group home setting of 15 residents. • Performed medication administration supervision of workers, reviewed medications ordered and coordinated medical care and follow-up treatment plans with their doctors.

Member Quality Supervisor

• Dec 2002 - Sep 2003

• Monitored, processed and investigated New Jersey state complaints. • Prepared and conducted state audits. • Performed studies and monitored the action plan for the member satisfaction survey. • Wrote and updated policies. • Supervised staff assistants and technicians. • Monitored, processed and investigated New Jersey state complaints. • Prepared and conducted state audits. • Performed studies and monitored the action plan for the member satisfaction survey. • Wrote and updated policies. • Supervised staff assistants and technicians.

QI Supervisor

• Jul 2000 - Jan 2002

• Collected, investigated, tracked and trended data for the purpose of identifying areas that needed clinical, professional or administrative improvement and prepared reports, agendas and minutes for QA committee meetings. • Reviewed clinical records, conducted new orientation and educational in-services related to continuous quality improvement activities. PPS and Oasis competent. • Conducted vendor audits and negotiated contracts. • Collected, investigated, tracked and trended data for the purpose of identifying areas that needed clinical, professional or administrative improvement and prepared reports, agendas and minutes for QA committee meetings. • Reviewed clinical records, conducted new orientation and educational in-services related to continuous quality improvement activities. PPS and Oasis competent. • Conducted vendor audits and negotiated contracts.

Supervising Registered Nurse

• Dec 1999 - Sep 2000

• Coordinated care of the mentally and developmentally disabled population within a group home of 15 residents. • Supervised medication administration: performed quarterly assessments and conducted pharmacological reviews for all clients. • Coordinated care of the mentally and developmentally disabled population within a group home of 15 residents. • Supervised medication administration: performed quarterly assessments and conducted pharmacological reviews for all clients.

Telephonic Case Manager

• Jan 1999 - Jul 2000

• Conducted telephonic reviews of services provided to members. • Assessed the appropriateness of the hospital stay from admission until discharge using Interqual Guidelines. Knowledgeable of NY commercial Medicaid and Medicare guidelines. • Pre-authorized patient services. • Tracked, trended and analyzed QA issues. • Surveyed contracted and non-contracted facilities and negotiated contracts. • Conducted telephonic reviews of services provided to members. • Assessed the appropriateness of the hospital stay from admission until discharge using Interqual Guidelines. Knowledgeable of NY commercial Medicaid and Medicare guidelines. • Pre-authorized patient services. • Tracked, trended and analyzed QA issues. • Surveyed contracted and non-contracted facilities and negotiated contracts.

Registered Nurse

• Jan 1998 - Jan 1999

• Provided nursing care and formulated care plans on a 35-bed treatment for life center unit for HIV, ESRD patients and multi-populated med-surg patients. • Charge nurse for 4 bed ICU unit on the same floor. • Provided nursing care and formulated care plans on a 35-bed treatment for life center unit for HIV, ESRD patients and multi-populated med-surg patients. • Charge nurse for 4 bed ICU unit on the same floor.

Public Health Nurse

• Aug 1997 - Jan 1999

• Reviewed physical exams and formulated charts in school based clinics for NYC public and parochial schools. • Provided First Aid and cared for traches, suprapubic catheters and gave medication prescribed for students such as diabetics, asthmatics. • Provided hepatitis B immunizations, taught Open Airways Asthma program and other preventative programs. • Reviewed physical exams and formulated charts in school based clinics for NYC public and parochial schools. • Provided First Aid and cared for traches, suprapubic catheters and gave medication prescribed for students such as diabetics, asthmatics. • Provided hepatitis B immunizations, taught Open Airways Asthma program and other preventative programs.

Registered Nurse

• Dec 1996 - Mar 1998

• Provided care of 50 residents on a unit with peg tubes, traches, Foley catheters, and oxygen therapy. • Administered medication and provided wound care. • Provided care of 50 residents on a unit with peg tubes, traches, Foley catheters, and oxygen therapy. • Administered medication and provided wound care.

Medical Research Coordinator

• Sep 1993 - May 1994

• Recruited people at high risk for HIV into an HIV research study conducted by researchers at NYU and Bellevue Medical Centers. • Provided HIV testing, education and follow-up of those chosen to participate in the study. • Handled IRB’s, entered data, pulled reports and analyzed data for the study. • Recruited people at high risk for HIV into an HIV research study conducted by researchers at NYU and Bellevue Medical Centers. • Provided HIV testing, education and follow-up of those chosen to participate in the study. • Handled IRB’s, entered data, pulled reports and analyzed data for the study.