Case Manager Utilization Review

Kimberly D. Bilbrey, RN

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

615-***-**** (mobile)

EMR skills - Last 5 years with EPIC and Cerner and also several years of Meditec

h in the past.

Professional Experience

Cigna

Acute Care Case Manager/Utilization Review Nurse 7/2019-5/2024

●Reviewing acute inpatient hospitalization requests, as well as post-acute requests using Interqual guidelines.

●Referring requests to MD for secondary review as needed.

●Notifying facilities of authorization status.

●Ensuring case management follow-up after discharge for SNP and other Healthspring Medicare members.

●

HMI, LLC 1/2018-1/2020

Outpatient facility charge capture specialist/coder

●Perform line by line review of client Charge master to ensure compliance with CMS OPPS regulations.

●Make recommendations for additions, modifications and deactivations.

●Make recommendations for changes in pricing as related to CMS reimbursement.

●Make recommendations regarding missed charging opportunities.

●Review department charge slips and make recommendations for updating.

●Perform Bill audits based of the various facility departments to determine the accuracy of the staff billing.

Blue Cross Blue Shield Tennessee 7/2018-12/2018

Supplemental Data Collection for HEDIS

●Supplemental data collection for HEDIS for Medicare Advantage, Commercial and Medicaid lines of business for multiple provider offices using multiple electronic medical record systems.

●Responsible for retrieval, review, and abstraction of medical record data, required for multiple and complex STARS and HEDIS measures as well as entering the data into Client’s quality program tool.

●Performing medical record review in the physician offices.

●Collaborate with clinical and non-clinical staff regarding provider scheduling and on-site medical record retrieval as needed.

AECOM/TeamHealth 6/15-09/17

Occupational Health Nurse

●Managing the care for injured and/or personal medical illnesses for employees.

●Follow-up care for injuries with escalation to the next level of care as needed and deemed appropriate based on guidelines.

●Collaboration with safety manager(s) involved in management of any injuries requiring follow-up care and/or escalation of care.

●Also performing urine drug screening, respiratory fit testing.

Cigna/QualityStaffing 3/16-6/16

Appeals/Utilization Review Nurse

●Responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication

●Researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal (utilizing Medicare NCD/LCD, Milliman, InterQual guidelines as applicable)

●Reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately

●Prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.

AscendManagement 10/14-7/15

Audit/Appeal

●Administer on-site assessments for individuals with medical conditions based upon review of records.

●Completing comprehensive functional assessment, including direct and in-depth observation of Activities of Daily Living (ADLs) and conducting an interview with the individual and family member and/or significant caregiver.

MedSolutions(Evicore) 2/12-10/14

Utilization Review Nurse

●Perform review activities for radiologic procedures that require preauthorization.

●Issue approvals for studies that meet specified guidelines or forward studies that do not meet the guidelines to the Medical Director.

MedView 8/10-2/12

RN Medical Review Specialist

●Contact potential new clients on behalf of medical malpractice law firms to determine answers to the following medical-merit questions: Is there a significant or permanent injury or damage? Is there an apparent or suggested deviation in the standard of care? Is there a link between the deviation and the injury or damage? Further review of medical records recommended?

●After the medical-merit evaluation is completed, the Medical Review Specialist summarizes the findings to support the recommendation, and the firm receives a written recommendation for the law Office to help determine medical-merit.

Hendersonville hospital in Hendersonville TN 8/11-11/11

Greenview Regional hospital in Bowling Green KY 11/09-6/10

Summer Regional Medical Center 1/08-8/09

Vanderbilt University Medical Center 6/06-5/07

Staff Nurse in Emergency Department

●Managing the care of patients with age ranges from 0-99+ years presenting with a variety of illnesses and injuries in multiple emergency departments.

●Providing patient/family education and continuum of care planning.

●Effectively communicating and collaborating with multiple health care team members, physicians, consulting/admitting physicians, social workers, hospital supervisors, etc.

●Participating in finding solutions for variances from patient goals and ensuring implementation of solutions.

●Ensuring efficient and timely flow of patients admitted and discharged through the emergency department.

●Also managed and provided care of patients in Sumner Regional Same Day Surgery Department on a PRN basis.

Education & Certification:

●Tennessee State University, Nashville, TN. Associate Degree in Nursing - May 2006

●License# 156197

Contact this candidate