Utilization review nurse, Utilization review coordinator, manager UM

Kathryn Pressley-Lints, RN

Parker, Colorado 813-***-**** *********@*****.***

PROFESSIONAL SUMMARY Utilization Review Nurse RN

RN license registered nurse with 6+ years of surgical perioperative nursing experience and 10+ years of care management experience in Medicaid, Medicare, and Commercial insurance benefit plans.

Behavioral, pre-service, concurrent and discharge planning experience

Worked remotely in utilization review from 2019 to 2022.

Developed and implemented the transitions care program. Preceptor all new hire staff. Initiated the start of new business in Hawaii market for aged, blind and disable population.

KEY SKILLS

Chart auditing, InterQual and Milliman evidence base criteria, NCQA guidelines, Interdisciplinary communication and coordination, telephonic patient management, single case agreements contracted for mental health services outside the state, analyzing, reporting, and correcting documentation standard issues under state contracts.

PROFESSIONAL EXPERIENCE

RN Utilization Review Coordinator Lighthouse Behavioral Health Hospital Conway, South Carolina 09/2022 – 07/05/2024

Fulfilling the role of UM review for acute inpatient medical necessity mental health and detox services.

Performed inpatient utilization reviews for adult, adolescent, and geriatric patients.

Performed concurrent reviews, intensive outpatient, and residential services when necessary.

Developed and updated training workflows and processes for other staff of daily UM work.

Initiated appeal letters to any non-approved inpatient behavioral services.

RN Prior Authorization PacificSource Health Plan Boise, Idaho 10/2019-06/2022

Fulfilling the role of prior authorization level of care for procedural, surgical, retrospective, behavioral and dental needs for commercial lines of business.

Completed medical necessity prior authorization reviews under Milliman criteria.

Collaborated with medical director for all services not meeting medical necessity.

Informed upper management of details missing in current policies to achieve completion of successful reviews.

Partnered with various staff within provider networks to ensure appropriateness of UM services.

RN Manager Utilization Management Blue Cross Idaho Boise, Idaho 08/2018 – 10/2019

Fulfilling the role of manager supporting the utilization department for medical, behavioral and transitions of care needs.

Created and initiated the start of Transitions of Care program for UM department.

Collaborated with medical directors in hospital rounds reported by the nurses to improve less inpatient stay days.

Partnered with non-clinical team lead to enhance and define work to better minimize unnecessary time needs.

Supported NCQA guidelines for daily processes.

RN Utilization Management Nurse EQ Health Solutions Tampa, Florida 05/2016-02/2018

Fulfilling the role of behavioral health liaison, prior authorization, and acute inpatient medical services for Florida Medicaid members.

Prepared out of state mental health contracts for behavioral inpatient services unattainable in current state.

Delivered medical review under InterQual criteria for acute medical inpatient, radiology, and durable medical equipment (DME) services.

Collaborative team member in preparation of timeline for accreditation renewal.

Facilitated in special projects initiated by upper management.

RN Supervisor of UM Elevations Care Centrix Tampa, Florida 09/2015- 04/2016

Utilization supervisor carrying secondary UM review team for DME Medicare/Medicaid services.

Participated in analyzing, creating, and evaluating reports relating to Medicare documentation requirement standards.

Conducted monthly performance reviews and education on providing proper age-appropriate documentation standards to member notification letters.

Initiated and participated in writing curriculum related to Medicare standards.

Provided aid to nursing staff related to daily issues of criteria understanding.

Analyzed and reported daily inventory of department service requests.

RN Supervisor Centene Health Plan Tampa, Florida 02/2015-09/2015

Supervisor of Utilization Management Review for acute inpatient members admitted to hospitals in the West Coast region.

Provided aid to nursing staff related to inpatient criteria standards using InterQual.

Analyzed, evaluated, and assigned daily hospital assignments.

Conducted monthly performance reviews and education on proper documentation standards related to inpatient criteria.

Worked with and partnered with clinical trainer to develop curriculum in health services standards.

RN WellCare Health Plan Tampa, Florida 2006-2015

Manager of Disease Management (2014-2015)

Successfully lead DM department through Georgia state audit.

Initiated emergency parameters for patient chronic condition management needs.

Revised existing policies to meet current NCQA standards.

Utilized problem-solving and project management skills for this position.

Oversaw nurse supervisor monthly education meetings.

Analyzed and delivered monthly case load achievements.

Developed and taught monthly auditing requirements.

Supervisor of Case Management (2011-2014)

Demonstrated creative ways to improve department standards through new case management programs offered.

Revised existing policies and training materials to educate on initial startup in-house behavioral case management requirements.

Conducted monthly performance reviews on nursing case managers.

Developed and outlined new case management programs.

Facilitated change of case management from long term to short term role in the state of Kentucky.

Utilization Review Nurse (2006-2011)

Participated in special projects for the Georgia Medicaid/ Medicare markets.

Conducted inpatient reviews for various contracted states including discharge planning

Preceptor to all new hire staff.

Participated in educating to review process for hospitals in Hawaii before go-live start date.

Worked with interdisciplinary team to coordinate evidence-based care across the care continuum from admission to discharge.

Educated to cultural differences during travel to south pacific islands during startup of Hawaii market.

LICENSES

Registered Nurse (RN) South Carolina Compact License 222316, Florida State Board of Nursing, License # 9179770, Idaho License # 57939, Missouri License # 201-***-****

Basic Life Support (BLS) American Heart Association, expires 03/18/2025

EDUCATION

Associate of Science in Nursing (ASN), Pasco-Hernando College, Brooksville, Florida, 05/2001

Associate of Arts in Business Administration, Miami, Florida, 1992

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