Patient Care Utilization Management
Resume:
Linda M Sutherland
Oregon, WI 53575
(Home 608-***-****
E-Mail ad5vxq@r.postjobfree.com
Profile
Review pre-payment and post payment claims to determine medical necessity appropriateness. Review individual itemized charges for high dollar claims of inpatient admissions (greater than $150,00), Used Medical Policies, Certificate language, and collaborate with physicians about itemized charges.
Assessed and managed common patient needs. Assessed client needs and recommended appropriate products or modifications. Counseled patients and their families on health and prevention issues. Discussed cases with physician and other health professionals to prepare comprehensive patient care plan. Exposed to orthopedic, neurological, OB-GYN, and general surgical cases, chronic pain. Provided prenatal care to expectant mothers and postnatal care to mothers and infants. Took patient history, performed physical assessments. Work effectively with customers able to identify needs, tactfully answer questions, and solve problems on a case-by-case basis. Ability to communicate effectively with customers, management, and staff.
Work Experience:
May 2011 -May 2024
Medical Claims Review IV/ Medical Review Nurse Analyst.
Dean Health Plan/ Medica. 1277 Deming Way, Middleton Wisconsin
Review pre-payment and post payment claims to determine medical necessity appropriateness. Review itemized charges for high dollar claims of inpatient admissions for medical appropriateness.
Review medical records, certificate language, pertinent Medical Policies and claims information.
2006-2011
Claims Auditor
State of Wisconsin (Division of Access and Accountability, Medicaid Audits). West Wilson Madison Wisconsin
Perform audits on Medicaid Providers, to evaluate compliance with established State Codes and regulations, coding and billing practices. Recipient records are obtained and reviewed along with prior authorizations, MD orders and billings for services that were provided. State codes, statues and pertinent Handbooks are reviewed to determine if the provider is compliant with their practices. Educate providers on the various rules and regulations. Make appropriate referrals to various State agencies, such as fraud, Department of Regulation and Licensing. Assist the Office of Legal Counsel to set up legal folders, research code and Handbooks, act as a resource person and testify at hearings. Training at CPT Boot Camp for coding.
2003 -2011
Staff Nurse
Meriter Hospital. 202 South Park Street, Madison, Wis.
RN responsible for the care of postpartum mother/baby couplets, high risk maternal patients and newborn nursery.
2005 – 2006
Triage Staff Nurse
Advanced Pain Management 3230 Deming Way Middleton Wisconsin. 608-***-****
Telephone triage, assessing client needs and directing them to the appropriate level of care by following established Physician guidelines and offering instructions. Pre-operative teaching for procedures such as Facet injections, Epidural Steroid Injections, Discograms, Intrathecal pump insertions, IDET procedures and Permanent Spinal Cord Stimulators. Assisting with rooming patients in the office environment. Communicate with Case Managers (Worker’s Compensation), Physical Therapists, Providers and Employers in updating health histories, treatment plans, goals and expected outcomes for clients with chronic pain issues.
2002 - 2005
Managed Care Coordinator,
WPS Insurance. Madison Wis.
Managed Care Coordinator responsible for performing pre-certifications for inpatient procedures, prior authorizations for outpatient services, utilization review for inpatient stays, Case and Disease Management for various insured participants. Reviewed claim histories, high dollar claims and inpatient complications. Worker Compensation claims in addition to those of the insured participants.
1996 - 2002
Telephone Triage Nurse,
Dean Health Systems. Madison WI.
RN responsible for telephonic triage using computer-based algorithms for various patient populations in order to direct them to the appropriate level of care.
1980 - 2001
Staff Nurse,
St. Mary's Hospital Medical Center. 707 South Mills St. Madison, WI
RN responsible for management and care of 32 bed maternity unit for postpartum mother/baby couplets, high risk antepartum patients, NICU and newborn nursery in a leadership capacity as well as a team member. Computer Skills MS Office.
Education:
1971
Dundee Community High School.
1972-1976
University of Wisconsin- Stevens Point.
Biology, Physical Education and Education major. GPA 3.25
1978-1980
Madison General School of Nursing. GPA: 3.6 of 4.0. Major GPA: 3.6 of 4.0.
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