Customer Service Clinical Review
Resume:
Las Vegas NV *****
ad5n6u@r.postjobfree.com
Kristi Bentley-Wright RN
Professional Summary
Innovative, results-oriented UM Nurse with 23+ years’ experience as Registered and 14+ years in managed care in Medicaid, Medicare, and Commercial lines of business.
Senior UM Nurse Healthhelp LLC (Houston, TX)
June 2009 - Current
Clinical Review SNR/Team Lead
Reported to the Clinical Group Manager
Responsible for leading 155 nursing staff
Managed Phone and Queue volumes
Training and mentoring all clinical staff.
Completed high level clinical decisions related to case review.
Responsible for compliance, conducts periodic one-on-ones with UM nurses
Mentoring and education of UM to offer tips on process improvement and clinical review
Ensures case-specific turnaround time (TAT) related to client SLA and regulatory compliance requirements met for their specified program.
Acts as a liaison between frontline staff and Medical Directors.
Clinical review Nurse
Performed clinical intake and certifies cases according to policies and procedures for Inpatient, Pre-Auth, DME, Specialized services, LTAC, SNIF and Behavior Health. Provides quality customer service through interaction with providers, administrative staff, and others.
Performed clinical intake and certifies cases according to policies and procedures.
Provides quality customer service through interaction with providers and administrative staff.
Collected and entered confidential information ensuring the highest level of confidentiality.
Maintains written documentation according to HHI’s documentation policy.
Provided ongoing telephonic education to providers and office staff related to the UM process.
Notable accomplishments
Maintained SLE to under 3 minutes.
Increased production by 15%, 98% quality audits of clinical reviewers
IRRs to ensure consistency in application of Healthhelp Criteria improving scores from 95% to 99%
Increased staff efficiency and compliance. Customer service satisfaction survey results went from 96% to 99.9%
Maxim Healthcare Staffing
Seven Hills Behavioral Health Hospital (Henderson, NV) October 2021 - August 2022
Psychiatric and drug rehabilitation nursing, assessments, admissions, care plans, medication
Managed Phone and Queue volumes
Family Home Health (Las Vegas, NV) March 2005 - July 2007
Adult, pediatric & OB in-home patient care, assessment, care, plans, meds, all equipment vital to patient care, arrange ancillary disciplines, education to patient and families in all aspects of care, transfer of care and mental/emotional support.
Valley Hospital (Las Vegas, NV) January 2005 - March 2005
Labor and Deliver: assessments, care plans, meds, all equipment to care, OR/test prep, education to patient/families in all aspects of care, transfer of care to one level or another, mental and emotional support.
Education
Associate of Science: Nursing: Community College of Southern Nevada: State of Nevada Board of Nursing License number: RN34867
Nevada Career Institute: Certificate of completion: Surgical technologist for all surgeries
References upon request
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