Utilization Review Customer Service

Tammy Pete, LPN

832-***-**** ********@*****.***

Summary: Compassionate and detailed oriented License Practical Nurse with 30 years of experience in healthcare. Exceptional communication skills, unparalleled clinical background and a desire for patient diversity and safety. Well organized in forward thinking and time management. I pride myself in recently obtaining utilization review experience with Remote Learning Services which empowers my foundation in hospital admissions and administrative knowledge.

Skills:

●Utilization Review

●Medical/Surgical

●Admissions Nurse

●Scheduling Coordinator

●Geriatrics/Adults/Peds

●Intakes/Assessments

●Evidence Based Practice

●Knowledge of Claims/Billing

●Managed Care, Medicare

●Attention to Detail

●Concurrent Reviews

●Procedure Coding/HCPCS

●Retrospective Reviews

●Admission Reviews/Intake

●Workers Compensation

●Discharge Planning/DME

●Quality Customer Service

●Critical Thinking

●Microsoft Office/Excel

●Multitasking/Prioritization

Employment:

Metlife, contracted by Axelon, New York

LPN/Nurse Consultant, Insurance - Sep/2023 to Jun/2024 (Contract)

●Review assigned cases to determine if Group Life or Disability insurance should be approved.

●Evaluate workflow, establish priorities for time sensitive assignments to ensure quality.

●Examines and processes Statement of Health applications; determines whether to return, put on

pending, deny, approve or request additional medical information.

Memorial Hermann Hospital, Texas

LPN/Admission Nurse, Surgical Services and Hospital Admissions - Nov/2006 to Apr/2023

●Reviewed criteria prior to scheduling pre-admit testing and hospital admissions.

●Created surgery accounts/charts with the correct coding and CMS regulations.

●Monitored, tracked, and conveyed important patient information to healthcare staff to help

optimize treatment planning and care delivery.

●Identified high-risk patients for targeted disease management to prevent complications.

●Kept all company systems and data, (including sensitive member data), secure and safe,

according to company data and security policies and all HIPAA guidelines.

●Communicated with patients, nurse team, physicians, and office to streamline the surgery/admission process.

St Joseph Hospital, Texas

LPN/Admission Nurse - May/2006 to Nov/2006

●Screened patient for admission status from ER and physician’s office to Admit/Transfer Center

●Obtain/verify insurance benefits and required prior authorizations.

●Maintained excellent customer service standards while providing compassionate care.

●Collected patient database information, communicated with case management and educated patients and family.

Professional Education:

Utilization Review-101, Certificate of Completion - 10/2023

●Remote Learning Services, LLC, taught by Marie Peppers LPN and Judy Clarke RN

Sowela Technical Community College, Licensed Practical Nurse

License: LPN, Texas - Compact, Current

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