STACI VESTEL, BS, RN

New Hampton, IA ***** 641-***-**** ad3vkp@r.postjobfree.com LinkedIn Profile

Utilization Review Nurse Professional Profile

Experienced and accomplished Registered Nurse with 15+ years of demonstrated expertise in the areas of patient relations, utilization review, case management, medical document management, and clinical operations. Exhibits strong attention to detail, written and verbal communication skills, and a natural ability to thrive in fast paced, changing, and deadline driven environments. Excels in efficiently allocating medical resources to ensure that each patient receives equitable and appropriate levels of medical care. Maintains a track record of success in finding the balance between fiscal needs of organizations and care needs of each patient.

Utilization Review & Concurrent Review Milliman & InterQual Care Guidelines ICD/CPT/HCPCS Coding Expertise

Facets/Jiva/Streamline/Altruista Multi-State Medicare & Medicaid Plans CMS/NCD/LCD Guidelines

Epic & Cerner Electronic Health Records Complex Case Management Clinical Documentation Improvement EDUCATION & CREDENTAILS

Bachelor of Science in Biology/Secondary Education, Upper Iowa University, Fayette, IA Associates Degree in Nursing, Northeast Iowa Community College, Calmar, IA Registered Nurse Licenses: States of Iowa (Compact State License from State of Residence), California, Hawaii, Nevada, Pennsylvania, Washington

PROFESSIONAL EXPERIENCES

Mindlance Consulting, San Diego, CA 06/23 – 12/23 (Contract End) Clinical Appeals Nurse (by Individual Contract Only) – Centene/Iowa Total Care

Conducts daily preparation of clinical information with relevant information related to the denied prior authorization.

Analyzes data from the original denial to ensure a detailed outline case summary is provided to the Medical Director for review of the appeal case in a timely matter.

Ensures compliance with responses and resolution of the appeal case within the plans set turnaround times. Key Accomplishments

Exhibited audit proficiency by consistently achieving compliant documentation at 100% accuracy, while maintaining proper turn-around time standards.

Resolved appeal cases by following established protocols within predetermined turnaround times. Toney Healthcare Consulting, Tampa, FL 07/21 - 12/22 (Contract End) Utilization Review Nurse Consultant (by Individual Contract Only)

Conducts prospective, concurrent, or retrospective utilization review/medical management for all medical inpatient and outpatient services.

Efficient use of the Milliman and/or InterQual guidelines for several Medicaid and Medicare state/federal plans.

Acknowledge the appropriateness of quality of care based on contract, federal, state, or URAC requirements. Key Accomplishments

Optimized appropriateness of healthcare services while ensuring alignment of quality of care with contractual, state, and URAC requirements.

Increased healthcare outcomes for diverse Medicaid and Medicare state/federal plans by applying Milliman and InterQual Guidelines

Amerigroup/Anthem, West Des Moines, IA 06/19 - 03/21 Nurse Case Manager/Utilization Management Nurse

Supports the integrated case management for members with physical and behavioral health complex and chronic care needs.

Collaborates with internal and external resources to meet identified needs of the member.

Performs concurrent review of medical records for medical necessity and continued stay, as well as risk management utilizing Milliman guidelines.

Key Accomplishments

Achieved 97%-member engagement through case management and implementation of antibiotic follow-up program for state plan, resulting in attaining 98% audit scores with documentation. New Hampton Nursing & Rehab/Kensington Place Assisted, New Hampton, IA 10/18 - 06/19 Community Relations Director/Admissions Coordinator

Community promotions and liaison to enhance civic partnerships.

Pre-admission assessment nurse coordinator.

Collaborated with transferring facilities and responsible partners in efficient timeframes. Zoetis, Charles City, IA 04/18 - 09/18

Occupational Health Nurse

Development and administration of professional operations in accordance with company policies, practices, procedures, and applicable regulations.

Secures and develops all records, equipment, and programs related to occupational health services.

Collaborates with workers compensation and short-term disability insurance companies for utilization review and case management of colleagues on these programs.

Key Accomplishments

Enhanced employee engagement rates by 85% through in-house health assessments and wellness programs

Secured and improved records, equipment, and programs integral to occupational health services. Select Medical Hospital, Des Moines, IA 07/17 - 01/18 Clinical Liaison (Long Term Acute Care Hospital-LTACH)

Serves as an advocate for patients and liaison for referring and accepting hospital during the pre-admission process and with patient transition period from referral location to LTACH.

Collaborate with clinical teams coordinating information with facility departments prior to patient admission to LTACH. Key Accomplishments

Fostered and maintained strong relationships with Internal Medicine and ICU departments within territory and provided educational information to staff, families, and patients. UnityPoint Allen Memorial Hospital, Waterloo, IA 08/15 - 07/17 SNF Navigator/Liaison and Clinical Documentation Improvement Specialist

Oversees and conducts inpatient utilization reviews for patient care in both ACO and Non-ACO affiliated skilled nursing facilities.

Critical liaison between corporate ACO, patient and family advocate, healthcare teams, and other agencies ensuring proper placement and health resource usage to meet patient needs.

Performs further concurrent reviews of medical records by applying MCG guidelines to determine medical necessity and continued stay while simultaneously contributing to risk management initiatives.

Consistently ensures full compliance with local, state, and federal regulations for federally funded healthcare programs. Leverages clinical expertise and coding knowledge to assure precise, accurate document of ICD-10- CM, CPT, and HCPCS coding.

Engages extensively with healthcare partners to guarantee that clinical information accurately reflected the level of service provided to each patient.

St. Croix Hospice, New Hampton, IA 05/14 - 05/15

Clinical Supervisor/Branch Director

Conducts overall direction of hospice services, interdisciplinary team and employment of qualified hospice personnel.

Establishes standards of care to comply with federal, state, and local regulations and guidelines.

Establishes, implements, and evaluates goals and objectives for hospice services that promoted the standards of quality towards the total organizational objectives and philosophy. Iowa Hospital, New Hampton, IA 03/12 - 05/14

RN Patient Care Manager

Manages the ongoing supervision of all direct care services and leadership for the Patient Care Team.

Supervising, evaluating and coordinating with the various component members of the Hospice interdisciplinary team (IDT/IDG) and provide daily support.

Patient advocate and coordinator for other social service and health care providers in the community involved in patient’s plan of care.

Telligen Health Management Systems, Des Moines, IA 10/11 - 02/12 Senior Utilization Review RN

Conducts prospective, concurrent or retrospective utilization review/medical management for all medical inpatient and outpatient services using the Milliman and/or InterQual guidelines.

Includes appropriateness of quality of care based on contract, state or URAC requirements.

Provides technical assistance, medical record review and support to provider staff and physician reviewers. MercyOne Medical Center, New Hampton, IA 04/10 - 10/11 Clinical Liaison/Informatics/Professional Healthcare Staff Educator

Primary support of clinical improvement initiatives, collaborated in planning, implementing and evaluation processes, ongoing projects related to professional clinical practice, education and information management with Cerner PowerChart Electronic Health Record.

Accountable for structure and standard of practice, educational relationships with various external groups while promoting positive customer relations.

Demonstrates knowledge of electronic course files in HealthStream; manage costs and budget; use process excellence concepts to manage delivery and quality of services; develope strategies for new employee orientation and on-going competencies.

UnityPoint Allen Memorial Hospital, Waterloo, IA 11/08 - 04/10 RN Case Manager/Utilization Management Nurse

Delivery of patient care management in collaboration with a multidisciplinary team.

Serves as a liaison between payers, healthcare delivery team, and outside agencies.

Performs concurrent review of medical records for medical necessity, continued stay and risk management utilizing Milliman and InterQual guidelines.

ADDITIONAL WORK EXPERIENCES

LPN Charge and RN Skilled Charge - PRN New Hampton Nursing & Rehab/Kensington Place Assisted Living, New Hampton, IA

Director of Assisted Living and Admissions Coordinator New Hampton Nursing & Rehab/Kensington Place Assisted Living, New Hampton, IA

Volunteer Person Nurse Clinician Self-Employed, New Hampton, IA

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