APRIL ISRAEL

Orange Park, FL ***** 904-***-**** ad2xfg@r.postjobfree.com linkedin.com/in/april-israel-25b85a81 UTILIZATION REVIEW NURSE

Exceptional proven experience as a Multistate Licensed Practical Nurse in ensuring efficient and effective utilization of medical services for optimal patient outcomes. Impactful professional conducting clinical reviews, collaborating with healthcare teams, and implementing evidence-based practices. Resourceful communication and analytical abilities, with a proven track record of maintaining regulatory compliance and improving patient care quality. Dedicated to promoting patient cantered care and cost-effective healthcare solutions. Core competencies include:

Utilization Review Prior Authorization Precertification Case Management Disease Management HIPPA Healthcare Effectiveness Data Information Set (HEDIS) state and federal regulatory compliance Team Player ACCOMPLISHMENTS

• Identified member needs and provides support to ensure necessary services are available during the transition period.

• Collaborated with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes.

• Prepared cases that do not meet medical necessity or criteria for medical director review. Communicated effectively with medical director regarding identified variances within the case against criteria utilized for medical review.

• Exceeded minimum production average of 16 medical necessity reviews a day that exceeds quality goal with over 90% accuracy on internal audits.

• Maintained professional growth and development through self-directed learning activities and/or involvement in professional, civic, and national/community organizations. EXPERIENCE

Centene May 2023 - Present

Prior Authorization Nurse

Promoted the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.

• Performed telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.

• Completed medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.

• Collaborated with various staff within provider networks and case management team electronically or telephonically to coordinate member care.

• Educated providers on utilization and medical management processes.

• Provided clinical knowledge and act as a clinical resource to non-clinical team staff. Enter and maintain pertinent clinical information in various medical management systems. (e.g., CMS, MCGs, InterQual). Crossview March 2023 - Present

Realty Realtor

Gathered, provided, and explained details of current market conditions, pricing, legal requirements, and similar information.

• Facilitated selling clients with pricing based on current market values.

• Assisted clients with staging properties for sale; hosted open houses and other promotional events. APRIL ISRAEL ad2xfg@r.postjobfree.com PAGE2

Relator February 2021 - March 2023

Veterans United Reality

Gathered, provided, and explained details of current market conditions, pricing, legal requirements, and similar information. Assists selling clients with pricing based on current market values. Assists clients with staging properties for sale; hosts open houses and other promotional events. Aetna/ CVS July 2006 - January 2021

Utilization Review Nurse/Pre-Authorization

Utilized clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

• Gathered clinical information and apply the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination and recommendation along the continuum of care.

• Communicated with providers and other parties to facilitate care and treatment.

• Identified opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.

• Consulted and lent expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. ADDITIONAL RELEVANT EXPERIENCE

First Coast Service Options

Medical Associate Medicare Part B department

Kelly Services

Medical Associate

University of Florida Jacksonville Physicians, INC Commercial Insurance Coordinator for the Department of Cardiology University of Florida Jacksonville Physicians, INC Charge Entry Processor OB/GYN Department

ATS Health Services

Medicare Part B Correspondence Analyst Customer Service LICENSE

Licensed Practical Nurse (LPN) (Multistate License) EDUCATION

First Coast Technical Institute - LPN Program.

Medical Secretary Diploma, Concorde Career Institute. COMPUTER SKILLS

Possess knowledge of medical computer applications through (e.g., CMS, MCGs, InterQual) GTE TCS IDX HBO

MCS system MCTEXT MediPass Medisoft WordPerfect Microsoft MediPass Med Compass ECHS Fax Central OPTUM360 EncoderPro.com Professional ClaimsX-ten McKesson Total Payment Solution.

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