Utilization Review Management

Kristy Jue, RN, BSN

Nolensville, TN ****@***.*** LinkedIn 925-***-****

Senior Healthcare Utilization Management/QA/Compliance Professional RN, BSN

Core Competencies

•Utilization Review/Quality Manager

•Acute care / ICU experience

•Home Health Nursing

•Oncology experience

•Microsoft Office (Word and Excel), Windows

•Physician Peer Review Experience

•Leadership / Training lead

•Field nurse educator for Genentech Nutropin team

•Pediatric nursing

•Answer clinical oriented questions

•Work in Matrix Organization with attention to detail

•Audit of clinical information for Compliance review.

EXPERIENCE

EQUUM Medical (Telehealth Organization) 2023–Present

Charge Nurse Brentwood, TN

Leads team of clinical monitors that manage patients through telemonitoring to prevent falls

Southern California Physicians Health Services Oct 2021-Dec 2022

Clinical Compliance Manager San Diego, CA

UM/QA management

Clinical Oversight

Medical Management

United Health Group 2021

Quality Oversight Manager San Francisco, CA

Monitored Covid testing and vaccine sites to ensure adherence to guidelines

Lash Group 2010-2012

Clinical Nurse Specialist San Bruno, CA

Education and Training of 30 Case managers on criteria and guidelines for Patient Assistance program eligibility

EMR review of medical necessity cases with medical director

Interact with Healthcare providers, patients and client representatives

United Healthcare 2009-2010

Medical Management Consultant Concord, CA

Act as a liaison between the healthplan and designated medical groups

Analyze medical group data to review trends and increase effectiveness in medical decision making

Develop strategies to improve authorization referral procedures

Meet with Medical Directors and review corrective action plans

Brown and Toland Medical Group 2006-Oct. 2009

Quality Assurance/Utilization Review Management Nurse San Francisco, CA

Provide comprehensive Utilization Management services using Interqual criteria, working in conjunction with the health care team, including health plans, the Centers for Medicare and Medicaid Services (CMS), physicians, and other health care providers.

Ensure members access to medically necessary, quality health care services provided at the appropriate level of care in a timely manner, while incorporating cost containment strategies. Review of all medications for delivery of specialty pharmacy providers and appropriate dosage and administration.

Perform patient assessment, planning, coordination, implementation and evaluation of services provided to Brown & Toland members and case management, while complying with NCQA, health plan and Brown & Toland Medical Group (TMG) guidelines.

Good Samaritan/Phoenix Childrens Hospital 1989-1993

Quality Assurance/Utilization Review Management Nurse Phoenix, AZ

Performed research on patient outcomes (drug studies)

Prepared and organized medical case information for medical review

Evaluated clinical environments to help identify strategies to improve nursing practice

Utilization review

Identified high risk admissions

Collaborated with Health Care team members

Conducted reviews of medical necessity

Coordinated with Social Services to arrange services post-discharge

Reviewed clinical practices of pediatric Residency Program

Member of Hospital Ethics committee

Good Samaritan/Phoenix Childrens Hospital 1982-1993

RN Staff Nurse Phoenix, AZ

ICU/NICO

Asthma and Pulmonary experience

Psychiatric

Home Health Nursing

EDUCATION & CERTIFICATION

Bachelor of Science University of Washington School of Nursing Bothell, WA

Health Services Management Certificate Gateway Community College

Associates Degree in Nursing Mesa Community College Mesa, AZ

LICENSES and CERTIFICATIONS

RN licenses active in CA, AZ and TN

Current certifications in CPR and Basic Life Support

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