Utilization Review Case Management
Resume:
Patricia Mann
Hoschton, GA *****
*************@*****.***
I have been a nurse for approximately 33 years. I have a lot of experience in med-surg, homecare, hospice, medical reviews and appeals, case management and utilization review. I would like to work part time but am also open to full time.
Authorized to work in the US for any employer
Work Experience
UR registered nurse
NGHS
December 2016 to Present
Utilization Review Nurse-
• Conducted comprehensive reviews of medical records to determine the appropriateness and necessity of healthcare services
• Collaborated with healthcare providers to ensure compliance with established clinical guidelines and protocols
• Evaluated patient treatment plans, including medications, procedures, and therapies, to optimize quality of care while minimizing costs
• Identified potential overutilization or underutilization of healthcare resources and recommended appropriate interventions
• Reviewed insurance claims for accuracy and completeness, ensuring adherence to reimbursement policies and guidelines
• Utilized evidence-based criteria and clinical expertise to make informed decisions regarding medical necessity and level of care
• Communicated review findings effectively through written reports or verbal discussions with physicians, nurses, and other healthcare professionals
• Participated in interdisciplinary team meetings to discuss complex cases, share knowledge, and develop collaborative solutions for patient care management
• Maintained accurate documentation of all review activities in accordance with regulatory requirements
• Provided education on utilization management processes to healthcare providers as needed RN Case Manager
Anthem Well Point Blue Cross Blue Shield-Atlanta, GA 2013 to Present
Responsibilities
Manage one of the highest caseloads with over 300 member client cases, mentor and precept new employees, participate in grand rounds, excellent time management skills. Medicare Appeals Nurse
Georgia Medical Care Foundation-Atlanta, GA
2012 to 2013
Responsibilities
Medicare Nurse Reviewer reviewing medical records for Medicare appeals, utilization review, and quality of care issues, Milliman and Interqual trained.
Director of Clinical Services
Maxim-Atlanta, GA
2009 to 2012
Responsibilities
Director of Clinical Services - South Office - 2011-12 Deputy Director of Clinical Services - North Office
- 2010-11 Case Manager - North Office
Responsible for Health Care Services and Case Management for clients; provide with Doctors & medical personal in-home health care & case management services; manage Clinical Staff, Case Workers & Contract Staff; Supervise Medical Procedures & Actions; Assist in personal decisions, provide overall staff management, develop office procedures & budget; Communicate with and provide organizational skills for staff; Medical Certificate of Need and Utilization Review RN Case Manager
InHouse Hospice & Gentiva-Kalamazoo, MI
2007 to 2009
Responsibilities
Responsible for Health Care and Case Management for patients; work with the Doctor and staff, provide in-home health care and case management services; Supervise the staff, make home visits in the field to examine the client and see that the staff provide appropriate health care; Medical Certificate of Need and Utilization Review
Registered Nurse - Charge Nurse Relief
Battle Creek Healthcare Systems, Borgess and Select Hospitals,-Kalamazoo, MI 1987 to 2003
Responsibilities
Working with the Patient Care Assistant; providing critical care; ventilating patients & appropriately & delegating shared patient responsibilities Education
ADN in Nursing
Kalamazoo Valley Community College - Kalamazoo, MI 1993 to 1996
Nursing Licenses
RN
Skills
• Case Management (8 years)
• Supervision (5 years)
• Utilization Review (9 years)
Certifications and Licenses
RN
1996 to 2016
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