Utilization Management Operating Room

April Worthy

**** ** **** ******, ****** City, Mo 64152

Phone # 816-***-****.

************@*****.***

SKILLS

Registered Nurse licensed in both Kansas and Missouri (compact state).

* *****’ experience in utilization management, 20 years’ experience in the operating room, 3 years’ experience telephonic nursing.

Excellent telephone and computer skills.

Meticulous.

Professional.

Computer skills: Microsoft Windows, Microsoft Excel, Microsoft Outlook, Guiding Care, QNXT, Siebel, Care Radius, XMedius Fax, ProFax, RightFax, Facets, Perceptive, Quick Base, Snag-it, Snipping tool, Verizon Virtual Contact Center, Avaya program for telephonic communication, Meditech EMR, and PowerChart EMR.

EXPERIENCE

4/1/22 – 1/22/24

BLUE CROSS BLUE SHIELD OF KANSAS CITY – BLUE KC

RN - Clinical Review Nurse-Government Programs, Utilization Management Dept. Prior authorization nurse for commercial and ACA health insurance. Reviewed clinical information and BKC and MCG guidelines to determine medical necessity of prior authorization requests. Write a brief synopsis. Route cases that do not meet criteria to the medical director for review. Send approval and denial determination letters to providers. Programs used: Guiding Care, Facets, Perceptive, Teams, Snag-it, Snip it.

11/5/2018 – 3/25/22

Aetna Better Health of Kansas, CVS Health.

RN – Utilization management/concurrent review clinical consultant. Reviewed clinical information from EMR or fax to determine medical necessity for authorization of inpatient acute hospitals stays, skilled nursing facility stays, inpatient rehab stays and LTAC stays. Participated in daily admission rounds with concurrent review team and medical directors. Faxing approvals and denials to the facilities. Speaking with UR Dept staff to obtain additional clinical information. Computer programs most frequently used: QNXT, Quick Base, ProFax, KMAP, Meditech EMR, and PowerChart EMR.

9/17/2018 – OCT/2018

United BioSource

RN - Nurse Navigator. Telephonic nurse providing pharmaceutical support services and clinical support for members taking specialty medications.

3/27/2017 – 6/29/2018

TriWest Healthcare Alliance

RN – Utilization management care coordination nurse for the veteran’s choice program. Collaborated closely with veterans, surgical providers, hospital/facility case managers, and the VA Medical Center. Coordinate insurance authorizations for patient surgery, hospitalizations, DME, inpatient and outpatient rehab, skilling nursing facility stays, home health, and discharge care needs. Completing authorizations and faxing prior authorizations to the provider. Completing pre and post calls to veterans to assess needs and facilitate care needs to the physicians.

7/15/2015 – 1/31/2017

Medix

RN – Call center nurse contractor through Medix for TEVA Pharmaceutical on the Shared Solutions Team. Provided telephonic patient education to members with multiple sclerosis taking Copaxone injections. Performed electronic medical documentation and supply requests in the Seibel program.

4/7/2014 – 6/15/2015

CenterPoint Medical Center

RN – Operating room circulating nurse. Duties included operating room set up, medical equipment set up and operation, preparing the surgical field, patient assessments, patient positioning and prep, assisting the operative team and electronic medical documentation.

1/1/2012 – 10/4/2013

Liberty Hospital

RN – Operating room circulating nurse. Circulating nurse for surgical procedures. Preparing the operating room, medical equipment set up and operation, setting up the surgical field, patient assessment, patient positioning and prep, assisting the operative team and electronic medical documentation.

7/31/2006 – 11/11/2011

Truman Medical Center

RN – Operating room circulating nurse and scrub nurse night shift. Primary duties: Circulated or scrubbed emergency and trauma surgeries. Setting up operating rooms, stock supplies, and preparing equipment for the next day’s surgical procedures. Circulated and scrubbed surgical procedures in all services including general, orthopedic, neurosurgery, urology, vascular, ENT, oral and maxillofacial, GYN, and plastics. Processed and sterilized instrumentation. Completed electronic documentation.

7/1/1996 – 11/12/2005 Plaza location

11/13/2005 – 6/15/2006 North location

Saint Luke’s Hospital

RN – Operating room nurse. Circulated and scrubbed surgical procedures in all areas of surgery. A member of the quality committee and later appointed the head of the quality committee by Debbie Cook Director of Surgical Services.

EDUCATION

5/20/1994

Johnson County Community College

Associate of Science Degree in Nursing

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