Utilization Review / Appeals RN

JANET HARRIS

**** ******** *****

Cincinnati, Ohio 45240

Home Phone: 513-***-**** / Cell Phone 513-***-****

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

Summary of qualifications

ACCOMPLISHED IN PROVIDING COMPASSIONATE, QUALITY MEDICAL CARE FOR ALL PATIENTS/CLIENTS

EXCELLENT COMPUTER SKILLS, CALL CENTER AND OFFICE SKILLS (FILING, FAXING, USE OF COPIER, ETC)

EXPERIENCE AS UTILIZATION REVIEW NURSE, CASE MANAGER, CIRCULATING/SCRUB NURSE, PACU/ RECOVERY ROOM NURSE, STAFF/CHARGE NURSE, MED SURG NURSE, PUBLIC HEALTH NURSE, AND NURSING SUPERVISOR

GOOD ORGANIZATIONAL ABILITIES – ABLE TO PRIORTIZE AND FACILITATE MULTIPLE TASKS EFFICIENTLY

KNOWLEDGE OF MEDICAL TERMINOLOGY, PROTOCOLS AND RESPONSIBILITIES

ABLE TO WORK AS A TEAM MEMBER – DEDICATED AND RESPONSIBLE – FRIENDLY AND PROFESSIONAL

**CURRENTLY LICENSED AS RN IN THE STATE OF OHIO**

Active Compact RN License since 3/17/2023

Education

BETHESDA HOSPITAL SCHOOL OF NURSING–XAVIER UNIVERSITY

ASSOCIATE DEGREE IN NURSING

Professional Experience

ROSE INTERNATIONAL/AETNA/CVS HEALTH NOV 7, 2022 – JAN 20, 2023

Worked using the QNXT and Med Compass systems

• Responsible for the review and evaluation of clinical information and documentation.

• Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations. Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. Data gathering requires navigation through multiple system applications. Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.-Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.-Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.-Commands a comprehensive knowledge of complex delegation arrangements, contracts,clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.-Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.-Condenses complex information into a clear and precise clinical picture while working independently.-Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

MORGAN STEPHENS DECEMBER 13, 2021 – MAY 16, 2022

CARE REVIEW CLINICIAN / UTILIZATION REVIEW NURSE (CONTRACT POSITION)

Responsible for reviewing clinical information/medical records sent in by the provider where the patient has been or is being treated. This medical information is reviewed by the RN against the Appropriate Medical Policy, Clinical Guidelines or the Milliman Clinical Guidelines which pertains to the specific diagnosis, test or treatment that the provider is requesting to be approved for the patient. If the patient meets the criteria found in the Medical Policy, Clinical Guidelines or Milliman Clinical Guidelines, the nurse will approve the provider’s request. If the nurse is not able to approve the admission at his/her level of review the information is then forwarded on to the Medical Doctor for them to complete the review.

AETNA/CVS HEALTH MARCH 19, 2018 – OCTOBER 4, 2021

Responsible for utilizing 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. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opp0ortunitiesw to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management.

ANTHEM /HSS (CONTRACT) NOVEMBER 21, 2016 –MARCH 1, 2018

UTILIZATION REVIEW NURSE

Responsible for reviewing clinical information/medical records sent in by the hospital/facility where the patient has been admitted. This medical information is reviewed by the RN against the Anthem Medical Policy, the Clinical Guidelines or the Milliman Clinical Guidelines which pertains to the specific diagnosis for which the patient has been admitted into the hospital. If the patient’s medical/clinical information meets the criteria found in the Anthem Medical Policy, Clinical Guidelines or Milliman Clinical Guidelines, the nurse will approve the patient’s hospital admission according the LOS (length of stay) that has been cited on the MCG. If the nurse is not able to approve the admission at his/her level of review the information is then forwarded on to the Medical Doctor for them to complete the review.

EVICORE HEALTHCARE- January 25, 2016 – August 29, 2016

UTILIZATION REVIEW NURSE

Responsible for reviewing cases and procedures to ensuring that patients receive the most appropriate test or treatment for their condition. I am also responsible for responding to calls throughout the entire day and conduct initial medical reviews speaking with people throughout the U.S. and managing a wide and diverse caseload. Using a clinical pathway that contains a diverse list of questions that specifically pertain to the particular requested CPT code/exam and/or clinical guidelines. If the nurse clinical reviewer (clinical reviewer) is unable to approve the case at her level, the case is then forwarded on for to a Medical Director for physician review. The Clinical Review Nurse is also responsible for reviewing clinical information that has been faxed or uploaded on the web.

SHEAKLEY UNICOMP - June 2014 – February 2015

(MCO FOR WORKERS COMPENSATION)

Utilization Management Nurse - Responsible for reviewing C9 forms that the providers use to make request for services and treatments such as PT, MRI, Chiropractic treatments, Surgeries, EMG, Hospital Admissions and Cortisone/Epidural Injections just to name a few. It is the UM nurses responsibility to review each C9 request against the medical records sent in by the providers. The nurse applies clinical knowledge to assess the appropriateness of each request and then makes the decision to either Approve or Deny the request. Some of these requests may need to be sent to the Medical Director for review (there is certain criteria for this). The UM nurse is also responsible for answering phone calls from the injured worker, medical providers and/or others involved in the case to answer any questions that they may have regarding the C9, the claim and etc. The UM nurses work hand in hand with the nurse case managers in assisting them with any information they may need to help them with getting the injured safely back to work. We work as a team with the medical dispute nurses and case management nurses and other providers of care.

ANTHEM/WELLPOINT – June 2005 – Sept 2012

UTILIZATION REVIEW NURSE MEDICAL REVIEW /PSCCR DEPARTMENT

Responsible for performing retrospective review and evaluation of medical services by analyzing member or provider submitted claims and available claim information. Essential duties included, but were not limited to: Assessed the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy, M&R criteria, Medicare carriers manual, and other materials such as documentation provided by the physician or other supplier. Applied clinical knowledge to assess the medical necessity, level of services, and appropriateness of care in cases requiring prospective, concurrent, or retrospective utilization review. Also, responsible for forwarding cases for review by level III MD if unable to approve at level II nurses level. Performed other related duties as assigned.

UTILIZATION MANAGEMENT NURSE RADIOLOGY DEPARTMENT

Responsible for working the Call Center in the Radiology Department – Taking 60 or more calls per day from ordering MD offices and using the American Imaging Management Guidelines and/or Anthem Medical Policy to do Pre Authorizations for Radiology Procedures such as CAT Scans, MRI’S, CT Bone Scans, Nuclear Stress Test, and others based on the patients symptoms, treatments and other clinical information to determine if the patient/client meets the criteria to authorize the requested exam. If the patient/client does not meet the criteria the UM Nurse is responsible for sending the request/case to AIM for MD review.

If the UM Nurse has been assigned to do faxes along with taking calls the nurse is also responsible for pre authorizing faxed request in the same manner as stated above.

LIFESPHERE HOME HEALTH Jan 2004- Nov 2004

(MAPLE KNOLL VILLAGE)

NURSE CASE MANAGER – Managed and coordinated the care of elderly clients. I was responsible for doing full head to toe assessments/review of systems on each client at every home visit. Also, responsible for assessing and observing medical compliance and the effectiveness and/or side effects of the client’s medications. Also had the responsibility of teaching the clients about their medications including the side effects. I also taught the clients about their disease process and what signs and symptoms to report to the nurse. Responsible for opening cases and assessing the clients need for skilled nursing, OT/PT, social services HHA and ETC. Responsible for doing Oasis as needed for admissions, discharges, transfers and resumption of care, along with care summaries.

SHEAKLEY UNICOMP May 2003- Nov 2003

(MCO FOR WORKERS COMPENSATION)

NURSE CASE MANAGER – Medically managed and coordinated the care of injured workers through the use of the telephone and computer.

I coordinated the care of the injured worker by talking to the BWC, Employers, Physicians and the injured worker.

Also took the necessary steps that would enable the injured worker to safely return to work as soon as possible. I referred the injured worker to vocational rehabilitation as needed. Communicated and coordinated care and discharge planning with hospital UR nurse regarding an injured worker who was currently in the hospital.

TRIHEALTH Aug 2001 – Oct 2002

1) BETHESDA NORTH HOSPITAL

PACU/ Recovery Room Nurse

2) GOOD SAMARITAN HOSPITAL

OR Circulating/Scrub Nurse

UNIVERSITY HOSPITAL July 2000 – July 2001

OR Circulating/Scrub Nurse

ORAL SURGERY DEPARTMENT (HOLMES DIVISION)

Monitored IV Sedated Patients

CINCINNATI HEALTH DEPARTMENT May1989 – July 2000

PUBLIC HEALTH CLINIC NURSE

Performed entrance interviews, recorded patient history and vital signs, performed EKG’s and gave injections. Member of triage team referred patients to medical specialists as ordered per MD and referred patients to social services as needed. Provided exit interviews, reviewed patient medications, gave flu shots, TB/PPD test and immunizations per MD order. Also in charge of tracking all mammograms and making sure that patients received their annual mammograms when due and followed up on all positive mammogram results.

UNIVERSITY HOSPITAL Nov1987- May1989

STAFF / CHARGE NURSE

Did complete head to toe assessments and review of systems on patients. Administered blood products, started IVS, inserted foley catheters, flushed central lines and changed central line dressings per protocol. Received physician’s orders and administered medications as ordered. Handled I & O’s, did patient admissions and discharges.

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