Rebecca Boadway

Utilization Review Management

ad0u15@r.postjobfree.com • 909-***-****

Yucaipa, CA

Patient-centric healthcare professional, well-prepared to streamline case management and utilization review functions. Track record of optimizing healthcare operations through strategic planning for cost reduction and high-quality care maintenance. Skilled in conducting thorough retrospective reviews to improve overall financial / operational efficiency and ensure compliance with healthcare regulations. Detail-oriented in recording case information using electronic medical records systems and producing statistical reports. Proactive communicator, bridging gap between nursing staff, physicians, and healthcare providers. Resourceful professional with track record of supporting colleagues across multiple roles and showcasing strong multitasking skills. Quick learner adept at grasping new computer programs and organizational processes, ensuring seamless adaptation to evolving workflows.

Areas of Expertise

● Quality Assurance

● Medical Claims Review

● Patient Advocacy

● Individualized Care Plan

● Emergency Intervention

● Resource Allocation

● Teamwork & Leadership

● Interqual and MCG Criteria

● Interdisciplinary Collaboration

Professional Experience

Inland Empire Health Plan, Rancho, Rancho Cucamonga, CA

Retrospective Clinical Claims Review Nurse (2021 — Present)

2012 — Present

Conduct medical records review using nationally recognized clinical criteria for in-patient medical necessity, contracts, lines of business, departmental policies, and procedures, resulting in accurate determinations and improved compliance. Foster effective collaboration between Medical Services and Claims departments while serving as Clinical Liaison. Identify and analyze potential denied services and admissions, categorized by lines of business, contract, facility, and cost. Present findings to leadership for informed decision-making and appropriate action.

●Expedited review of inpatient claims, ensuring timely authorization, denial, appeals, and resolution of disputed claims to meet regulatory requirements and obtain necessary clinical information, thereby reducing unauthorized claims.

●Applied expertise in Millimen criteria, DHCS medi-cal guidelines, and NCAA standards as well as initiated quality assurance event reviews, resulting in enhanced quality assurance and successful referrals.

Inpatient Review Case Manager (2012 — 2021)

Accessed electronic medical records and collaborated with case managers, physicians, care providers, and team members to determine a suitable plan of care and discharge based on individual needs. Made referrals for disease management, high resource utilization, and behavioral health diagnoses. Enhanced care transitions by proactively engaging with hospital case managers and physicians, addressing discharge barriers, and authorizing necessary follow-up visits and outpatient procedures to ensure resource availability upon discharge.

●Improved outcomes and decreased readmissions by utilizing InterQual and Milliman criteria to review and approve/deny hospital stays.

Redlands Community Hospital, Redlands, CA

Registered Nurse Case Manager

2011 — 2012

Assessed patients' medical conditions, identified their healthcare needs, and developed individualized care plans. Coordinated patient care by collaborating with healthcare professionals, including physicians, and therapists. Advocated for patients' rights, ensuring they received appropriate and timely medical treatments and services. Documented patient care activities, maintaining accurate and up-to-date medical records in accordance with established protocols and privacy regulations.

●Evaluated and met discharge needs upon admission while collaborating with patients, families, and physicians and discussing options available with their insurance plan.

●Carried out admission, concurrent, and discharge reviews using Interqual criteria.

Additional Experience

Legal Nurse Consultant, Exemplar Legal Nurse Consulting, Self-Employed Business, Yucaipa, CA

Home Health Nurse, Case Manager, Redlands Community Hospital, Redlands, CA

Registered Nurse, Team Leader, Loma Linda Outpatient Surgery Center Post Anesthesia Care Unit, Loma Linda, CA

Registered Nurse, Loma Linda Pediatric Observation Unit, Loma Linda Children’s Hospital Outpatient Unit, Loma Linda, CA

Registered Nurse, Critical Care Transport, Loma Linda University Medical Center, Loma Linda, CA

Education

Associate of Science in Registered Nursing Associate of Science in Medical Secretary

Pacific Union College

License

Registered Nurse, California Board of Nursing, expires April 2025