Patient Care Prior Authorization

DeAnna Thomas, RN

Clayton, N C 910-***-**** *********@*****.***

PROFESSIONAL SUMMARY

Dedicated and detail-oriented RN with 14 years of comprehensive experience in MedSurg and cardiac stepdown nursing, complemented by management expertise. Proficient in clinical review processes, utilizing critical thinking and decision-making skills to assess medical record documentation against established criteria and guidelines. Adept at conducting utilization reviews, prior authorizations, and retrospective reviews, while ensuring compliance with policy and regulatory standards. Committed to continuous professional development and training, with a strong focus on improving processes to enhance quality and client satisfaction. SKILLS and STRENGTHS

Clinical reviews, medical record documentation, Clinical criteria, Coverage policies, Utilization guidelines, Critical thinking, Decision-making skills, Documentation accuracy, policy support, Regulatory compliance, Prior authorization, Precertification, Retrospective reviews, Training and mentoring, CEUs, cross-training, Process improvement, Auditing, Technology enhancements, problem-solving skills, time management, knowledge of medical terminology, patient care standards, adherence to regulations, proficiency in Microsoft Office Suite, Milliman (MCG) and InterQual.

RN Unit manager, Rehabilitation Unit Liberty Commons, Benson, NC (01-24 to present)

• Conducted comprehensive clinical reviews of medical records to assess appropriateness and necessity of services based on established clinical criteria and coverage policies.

• Applied critical thinking and decision-making skills to interpret medical documentation, ensuring compliance with utilization and practice guidelines while meeting production goals and quality standards.

• Documented findings and rationales for review decisions, providing clear justifications for approvals or referrals to physician consultants within contractual deadlines.

• Executed prior authorization, precertification, and retrospective reviews, preparing accurate decision letters to support the utilization review contract and facilitate effective communication.

• Trained and mentored staff by monitoring performance, providing constructive feedback, and enhancing their understanding of clinical policies and procedures. RN Staff Nurse, Rapid Staffing, Durham, NC (1-2023 to 5/2024)

• Maintained up-to-date knowledge of clinical criteria and guidelines by completing required continuing education units (CEUs) and participating in scheduled training sessions and meetings.

• Initiated and managed referrals to physician consultants when necessary, ensuring thorough communication of denial reasons and recommendations to facilitate patient care continuity.

• Collaborated effectively with interdisciplinary teams, enhancing communication and information flow between nursing, medical, and administrative staff to optimize patient outcomes and service delivery.

• Implemented quality assurance measures to monitor compliance with clinical policies and regulatory standards, contributing to continuous improvement initiatives within the organization.

Staff development Coordinator RN, Sunnybrook Healthcare and Rehabilitation (9/2022- 92023)

• Utilized analytical skills to identify trends in clinical data and review outcomes, proposing actionable insights to management for improved processes and patient care strategies.

• Prepared and presented educational materials on clinical criteria and review methodologies to staff, ensuring a thorough understanding of requirements and enhancing overall team competency.

• Participated in performance improvement projects, collaborating with leadership to enhance clinical workflows and reduce review cycle times while maintaining high standards of accuracy and quality.

• Ensured compliance with federal and state regulations, actively monitoring changes in healthcare policies to adapt practices and maintain organizational compliance. Conducted retrospective chart audits to evaluate compliance with clinical guidelines, providing feedback and recommendations to improve documentation practices among nursing staff.

RN Staff Nurse, Chest pain center/Step Down, Cape Fear Valley, Fayetteville, NC (01-2020 to 8/2022)

• Reviewed and interpreted medical records to assess compliance with clinical criteria, ensuring documentation supported the need for services in alignment with coverage policies and guidelines.

• Applied critical thinking and decision-making skills to determine the appropriateness and reasonableness of care while meeting production goals and maintaining quality standards.

• Documented decisions and rationales to justify review findings, ensuring clear communication of outcomes and recommendations to relevant stakeholders.

• Initiated referrals to physician consultants when necessary, processing their decisions to ensure denials were adequately detailed and completed within contractual deadlines.

• Performed prior authorization, precertification, and retrospective reviews, preparing comprehensive decision letters to support the utilization review contract requirements EDUCATION / LICENSURES / CERTIFICATIONS

Master of Nursing in Education, University of North Carolina at Pembroke (12/2019) Associate Degree in Nursing (ADN), Sandhills Community College (5/2014) Bachelor's of science in Nursing (BSN), University of North Carolina at Pembroke (12/2017) Licensed Practical Nurse (LPN Diploma), ECPI Medical Career Institiute (7/2010) HEDIS Fundamentals Certificate, Optimal Living Academy, (8/2024) Utilization Review Fundamentals, CCM, HEDIS Marie Peppers (12/25 to present)\ Registered Nurse, North Carolina, Compact #270627, Active

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