Sally A. Simons

**** ********* *****, ********** ** 23113 804-***-**** ad0f04@r.postjobfree.com

Objective

To provide exceptional rehabilitation nursing experience, utilization review expertise, and training

knowledge in a collaborative team environment.

Professional Experience

Aetna, Utilization Review Management Reviewer, Richmond VA June 2017 - July 2020

Reviewed medical records of members to determine medical necessity of admissions to

facilities using standard criteria.

Documented and communicated all aspects of the utilization/benefits management

program.

Acted as liaison between Aetna and providers.

Assisted with discharge planning.

Participated in daily comprehensive staff rounds.

Performed claims reviews.

VCU Health, RN Care Coordinator, Richmond, VA October 2011-May 2017

Medical record review for appropriateness of admission using Milliman and Interqual criteria

and communication with insurance companies.

Collaborating with social workers and interdisciplinary team members regarding discharge

planning and utilization review.

Arranging Home Health, DME, and transportation for patients.

AdvanceMed Corporation (CMC), Medical Review Specialist February 2009-2011

Provide utilization review and analysis of Medicare claims to determine payments using

CMS and other national guidelines.

Utilization of ICD-9, CPT-4, and HCPCS Level II coding principles.

Applying the interpretation of ANSI Reason Codes, Revenue Codes, timely AC edits and

audit codes, and other Medicare billing formats in order to determine appropriate billing

submissions and reimbursement.

Adherence to the Program Safeguard Contractor’s (PSC) policies and contract

responsibilities.

Virginia Premiere, Hospital Corporation of America, and St. Mary’s Hospital April 2007 –

February 2009

Reviewed medical records of members to determine medical necessity of admissions to

facilities using standard criteria.

Collaborating with social workers and interdisciplinary team members regarding discharge

planning and utilization review.

Arranging Skilled Nursing Facility admissions, Home Health, DME, and transportation for

patients

Optima Health, RN Case Manager, Richmond, VA January 2005-April 2007

Conduct inpatient admission evaluations to determine level of services needed for local and

state hospitals.

Provided case management of long term or chronic care cases.

Developed and implemented home program services for clients upon discharge

Trigon/Anthem Health Keepers, HMO Nurse Advisor, Richmond, VA December 1994-

January 2005

Telecommunications nurse for three years performing pre-certification for hospital

admissions, assigning length of stay based on clinical criteria and assisted with discharge

planning.

Determined appropriateness of referrals while adhering to medical necessity criteria,

subscriber benefits and consultation with the Medical Director if it became necessary.

Participant in multiple committees and programs.

Created and implemented a Utilization Management Manual for a training model and quality

program manual by other areas including Medical Management, Priority, and Peninsula.

Coordinated with various departments such as Medical Management, Provider Network

Management, Clinical Appeals, Configuration, and Call Center.

Performed trend reporting with providers and Medical Management to decrease pended

cases and focus on cost containment for overall operations of the department.

Education

Licensed Registered Nurse, RN – Binghamton General Hospital School of Nursing

Skills

Microsoft Office: Word, Excel, Outlook, Internet Explorer

Interqual and Milliman

Macess

Trimed

Amisys

HCA software systems

Meditech

Cerner

Midas

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