Utilization Review RN

G L. Z

PO Box ***, ***** Main Street, Macdona, TX 78054 • Home: 210-***-**** • Cell: 210-***-**** • ********@***.***

Professional Summary

Nurse Case Manager with valid Texas RN License. Solid clinical, utilization review and case management experience within a managed care environment over the past 30 years. Extensive computer skills, case management training and experience, neonatal intensive care, pediatric and obstetric specialty review experience. Supervisory and management experience with excellent communication skills.

Skills

Utilization review Strong clinical judgmentInterQual, Milliman and specialized criteria Palliative care awarenessapplication PreceptorDRG grouping Successfully directs staff meetingsICD-9-CM/ICD-10-CM coding High level of autonomyCase Management Qualified in healthcare billingCMS guidelines Patient/family focusedQuality Review Patient evaluation/interventionWebStrat, on-line application proficient Problem resolution capabilityMultidisciplinary coordination Adept at prioritizing/managing deadlines

Work History

Utilization Manager, RN, 11/2007 to 08/2017 Amerigroup Corporation (Anthem) – San Antonio, TX Performed inpatient and outpatient utilization review, discharge planning assessment and coordination,quality of care assessment, and coordination of case management services for Star and Star Plus dual and non-dual (Medicaid/Medicare) members for the state of Texas. Coding, criteria use, computer entry and routing; and multidisciplinary care coordination performed within this role. Coordinated initiatives and rounds for high risk utilization members, served as a subject matter expert to review team for neonatal intensive care and obstetric reviews and coding. Efficient utilization reviewer working effectively as independent telecommuter with on-line electronic medical record reviews and excellent communication skills (telephonic, electronic messaging and computer based programs).

Utilization Review/Discharge Planning=>Supervisor, 01/2007 to 11/2007Nix Hospital – San Antonio, Texas Concurrent inpatient admission and continued stay review, coding and preliminary DRG grouping,quality of care screening and multidisciplinary patient care planning and coordination. Reported to multiple hospital departments for process improvement. Participated in planning meetings for implementation of present-on-admission coding integration. Earned a reputation for excellence in service delivery and recognized by administration for going beyond the basics.

Education

Bachelor of Science: Biology, 1977 University of Houston - Houston, TX

Associate of Science: Nursing, 1981 San Antonio College - San Antonio, TX

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