Utilization Management Critical Care
Resume:
Scott Allen, BSN, RN
Kernersville, NC
*****.*****.**.**@*****.***
Summary
High performing, collaborative and integrity driven Registered Nurse with advanced skills in Care Management, Utilization Management and Critical Care. Stellar attention to detail ensuring accuracy and compliance with CMS and NCQA guidelines. Champion of coordination, collaboration and communication when providing patient specific, individual, age appropriate, high quality nursing care to patients. Well versed in InterQual Care Criteria and certified in MCG. Proficient in working with patients who have complex medical and behavioral conditions by utilizing advanced problem-solving skills to remove barriers, provide holistic, integrated care within a multidisciplinary team. Driven to surpass productivity metrics in my next role.
●MCG - Milliman Care Guidelines
●Utilization Management
●Medicare & Medicaid guidelines
●Care Coordination
●Discharge Planning
●Telephonic Case Management
●Motivational Interviewing
●Emotional Intelligence
●Critical Care
●Epic EMR super user
●Quality & Risk Management
●Clinical Review
●Critical Thinking
●Goal Setting
●DME Ordering
●Telehealth & Triage
●Primary Care
●InterQual Level of Care Criteria
Experience
Utilization Review Nurse at University of Texas Southwest - (remote)
June 2022 to Present
●Conducted comprehensive inpatient admission reviews at a large level one trauma center for Medicare, Medicaid, private insurance, and self-pay patients, ensuring compliance with evidence-based guidelines such as Milliman Care Guidelines to determine appropriate hospital level of care or observation services.
●Collaborated with the medical team—including admitting physicians and the access management team—to evaluate the necessity of acute care services, offering guidance on documentation improvement when needed to support hospital admission qualifications and ensure accurate level of care determinations.
●Served as a key resource to medical staff by advising on national and local coverage determinations, documentation requirements, and utilization management protocols, helping to ensure accurate and compliant admissions, while supporting cost-effective, high-quality care delivery.
●Identified and reported avoidable days and quality issues through detailed analysis of patient flow and progression of care, working with leadership to recommend interventions and improve clinical outcomes, while actively participating in performance improvement initiatives.
Utilization Review Nurse at Atrium Health Wake Forest Baptist Health - (remote)
June 2020 to October 2024
●Specialized in utilization review for pediatric, medical-surgical, oncology, and cardiac patients, ensuring timely and accurate assessments of medical necessity and level of care using evidence-based guidelines to determine appropriate hospital services.
●Collaborated with multidisciplinary teams, including social workers, case managers, physicians, and third-party payers, to facilitate appropriate patient placement and secure authorization for hospital stays, ensuring compliance with state, federal, and payer-specific regulations.
●Communicated comprehensive clinical information to third-party payers, ensuring timely authorization of care and providing feedback to the care team on payer requirements, denials, and strategies for securing approval for necessary treatments.
●Partnered with physician advisors and payer representatives to resolve payer denials and address discrepancies in medical necessity and level of care determinations, ensuring alignment between payer guidelines, clinical documentation, and patient care plans to optimize reimbursement and minimize delays in care.
RN Case Manager at Optum Services, UnitedHealth Group - (remote)
August 2016 to June 2020
●Provided telephonic care coordination and clinical review of medical records to assist managed care patients with cost effective utilization of benefits and avoid unnecessary hospital admissions.
●Identified knowledge deficits, provided free community resources and psycho-social supports to prevent gaps in care. Assisted patients in creating action plans by using SMART goals.
●Participated in department-wide special projects in collaboration with management to achieve targeted clinical strategic performance goals.
●Used motivational interviewing technique to provide chronic care management in recently discharged patients to assess for understanding of disease processes.
RN Primary Care at Wake Forest Community Physicians - Advance, NC
January 2015 to August 2016
●Performed telephone triage, assessed patient status and determined need for treatment interventions.
●Completed documentation and provided clinical updates for FMLA (Family Medical Leave Act) and medical necessity paperwork.
●Implemented appropriate care course of action in compliance with clinic and company
policies and procedures.
●Communicated with providers and insurance companies to coordinate care and follow up for
specialty referrals, ordering DME, supplies, prior authorizations, and home care services.
●Demonstrated exceptional capacity to multitask and manage competing priorities with ease while fostering delivery of superior patient care.
RN Critical Care at Wake Forest University Baptist Medical Center - Winston-Salem, NC
April 2008 to December 2014
●Provided exceptional bedside skilled nursing care in a fast-paced critical care setting.
●Acted as a float nurse to accommodate various units throughout hospital and primary care clinics: cardiac care, wellness biometric screening events, ambulatory care and PACU.
●Effectively managed ventilators, tracheostomies and multiport IV infusions.
●Managed all facets of telemetry, including central catheters, high risk drug administration and titration, thrombolytic therapy, dysrhythmia interpretation, and management.
Education & Certifications
Bachelor of Science in Nursing: Winston-Salem State University
MCG Certified: Milliman Care Guidelines Utilization Management Specialist
CCM - Certified Case Manager: Commission for Case Manager Certification
Licenses
Registered Nurse: licensed in the state of North Carolina (Multi-state compact), New York, California
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