Utilization Review Practical Nurse

April Israel

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

Orange Park Florida 32065

Cellular 904-***-****

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

Looking for a challenging role as an Utilization Review Nurse in the field of nursing that will enable me to use my 15 years of experience in the medical field. To provide exceptional people and communication skills. Friendly, detailed oriented individual with medical and people skills seeking employment as an LPN Summary of qualifications

• Licensed Practical Nurse

• Exceptional knowledge of utilization review, case management and disease management.

• Solid understanding of state and federal regulatory requirements affecting care coordination services, specifically CMS, Commercial and HIPPA

• Proficient in Microsoft Word, Excel and utilization review modules in information systems.

• Ability to work as a team member to strategize future program enhancements.

• Ability to provide commitment to excellence in nursing and to communicate well with frail elderly and providers.

Work Experience

2006 – present Utilization Review Nurse June

Aetna/ CVS

Utilizes 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 opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

2003-2006 Medical Associate Medicare Part B department First Coast Service Options

Effectively review Medicare appeals based on Medial policies and the Medicare Law. Research and enter data in the system. Provider providers and beneficiary’s information concerning their medical policies and denied Medicare claims. Perform adjustments on claims that have been denied and processed incorrectly. Develop free form letters and utilize system letters to send to providers and beneficiaries concerning their claims. Reopen Medicare Secondary Payer claims based on Medicare guideline. Develop resourceful quality tips to enhance team members work performance. Make phone calls to providers, and beneficiaries with Medicare to request additional data. Make decisions on denied claims based on the Medicare guidelines. Compensate providers and beneficiaries on claims that are payable based on Medicare guidelines. Use Microsoft Excel to manage workload. Utilize the Medicare Claim System (MCS) and HIMR applications to research claim.

2002-2003 Medical Associate

Kelly Services

Responsible for the professional review of post payments Medicare B Appeals, identifying potential fraud and abuse of Medicare in accordance with CMS rules and regulations. Resolve issues relative to claims processing in order to improve timeliness, quality and cost effectiveness of the Medicare program. Respond to customers relative to the result of the professional review as to whether the result is to affirm original claim payments and or adjust claim for additional payment. 1999-2001 Commercial Insurance Coordinator for the Department of Cardiology University of Florida Jacksonville Physicians, INC Maintain assigned carrier of financial class aging primarily through PCS work files. Answer incoming correspondence and telephone inquiries. Maintain all denial EOB s and provided feedback. Attain the budget collection rate for assigned category. Perform follow-up on special accounts request completion. Ensure proper payments, adjustments, deductible and co-insurance are billed after primary payments while insuring accuracy with explanation of benefits.

1997-1999 Charge Entry Processor OB/GYN Department University of Florida Jacksonville Physicians, INC Data entry, enter medical charges in a timely manner, Medical coding, Ensure that proper insurance guidelines for patient insurance carriers. Obtain authorization for patient visits 1996-1997 Medicare Part B Correspondence Analyst Customer Service ATS Health Services

Handling correspondence files for Medicare review, handling files in a timely manner, data entry on GTE system.

LICENSE

Licensed Practical Nurse (LPN)

EDUCATION

2004-2005 First Coast Technical Institute- LPN Program 1995-1996 Medical Secretary Diploma, Concorde Career Institute 1992 High School Diploma, Andrew Jackson Senior High School COMPUTER SKILLS

Possess knowledge of medical computer applications through GTE, TCS, IDX, HBO, MCS system, MCTEXT, Medipass, Medisoft WordPerfect, Microsoft, Medipass, Med Compass, ECHS, Fax Central, OPTUM360 EncoderPro.com Professional, ClaimsX-ten, McKesson Total Payment Solution, References available upon request

Contact this candidate