Utilization Review
Resume:
Betsy McConnell LPN
Multi State Compact license
Oregon license
***************@*****.***
Objective
I am extremely well versed in clinical software, training, managed care and the vast growing field of utilization review demonstrating years of clinical experience and an expansive medical case management background as well. I have a significant knowledge base not only medically, but that which also includes clinical practices, laws and a variety of state statues as well pre-authorization turnaround deadlines and workflow processes, triage etc. I have also appreciated and related effectively within the realms of healthcare management that serve as an integral part of this field; legal, business, regulatory affairs, human resources, employee and labor relations and social services issues involving diverse cultures and backgrounds etc. I look forward to sharing my goals to; participate in and facilitate quality of life and dignity for individuals, work as a team with colleagues, clients and their families as well as the community to make this possible in providing education, guidance and excellence in an holistic approach to patient and family care and customer service for optimal outcomes. I have enjoyed participating in special projects and welcome the opportunity to exhibit such creative abilities. I have contributed to many situations whereas my extensive research and knowledge have proved beneficial and successful. In addition, having realized the many rewarding benefits of my experience to ensure optimal healthcare outcomes and quality of life, I have a strong desire to continue to make this a part of my growing professional career. I am looking forward to the opportunity for an open discussion on these topics and my future endeavors with you.
Work Experience
Utilization Review Nurse, Case Review Specialist, Quality Improvement Specialist, Outreach Manager
8/2023-present Health Services Advisory Group (Contracted position through Medix)
Applying vast knowledge base and clinical background while reviewing Medicaid behavioral health claims and aiding in fraud investigation. Also performed as Quality Improvement Specialist and Outreach Manager in a project involving a special CMS directive. As part of a team effort, sharing knowledge with goal toward quality, customer service and providing cost savings to our clients.
Initial Clinical Review Nurse
6/2012-1/2023 Magellan Health Services/NIA
Applying vast medical knowledge base and clinical background while reviewing requests for diagnostics. As part of a team effort, sharing knowledge (medical or otherwise) with goal toward quality, customer service and providing cost savings to our clients. Audits. Training new hires. The Knowledge Center Team. Mentoring. Special Projects.
Home Health Case Manager
11/2022-present Angels of St. Louis
Providing in home skilled nursing care to patients. Assessing and charting observations of patients at each visit. Providing instruction and education to patients and their families on home health procedures and strategies.
Assistant Director of Nursing
9/2010-5/2011 Garden View Care Center
Responsible for assisting Director of Nursing to run Nursing department. Responsibilities; staffing, care planning, MDS, QI/QM, supervising a very large number of staff members. As compared to 6 months prior to my employment, MDS and care planning up to date, Medicare revenue increased by over $200,000.00 and with staffing some months showed to be $20,000.00 under budget for the first time, staffed well, and efficient with an overall improvement in nursing care.
Utilization Management Nurse
10/2009-5/2010 Coventry/Healthcare USA
ICD-9 AND CPT coding, utilization management, medical record review for Healthcare USA
Clinical Assistant and Home Healthcare Nurse
5/2008 – 9/2009 Angels of Mercy Healthcare Inc.
Responsible for quality review of 485 forms for Medicare reimbursement, OASIS and software utilization for this. Providing quality care and care coordination for clients and their families.
Clinical Software Support & Trainer
10/2006 - 4/2008 MDI Achieve, Maryland Heights, Missouri
Clinical software support specialist educating, supporting and training other medical professionals and fellow nurses how to use e-charting and other medical software for Care Plan Coordination, Medicare reimbursement, MDS etc. Running test data and generating reports for our clients as well for internal purposes utilizing software.
Nurse Researcher/Reviewer, Project lead
6/2006 – 10/2006 (per diem/seasonal/contract) Outcomes Inc., Tampa, FL
Medicare complete reimbursement chart audit review serving as project lead/site supervisor involving HEDIS reviews and other projects.
Utilization Review Nurse, Nurse Case Manager
6/1998 - 12/2005 Concentra Integrated Services, Hazelwood, MO
Applying vast medical knowledge base and clinical background while reviewing requests for medical treatment utilizing a variety of different nationally recognized medical guidelines to determine medically necessity vs. preparing reports, gathering information for and sending to a physician advisor for review. Transcription, Medical management, Disability management, care coordination/planning, triage and some catastrophic medical management. Account attaining, building, managing efforts. As part of a team effort, sharing knowledge (medical or otherwise) with goal toward quality, customer service, reflecting and reporting cost savings etc. Served on committee to develop/revise national internal treatment guidelines for company with medical director Dr. Melissa Bean.
Clinical LPN
9/1997 – 6/2010 (per diem/contract) Nursefinders, Brentwood, MO
Vast array of clinical settings experience; home health care, hospice, ambulatory, rehabilitation, hospital and intermediate care facilities as well as medical/surgical etc.
Previous to this and since 1988:
Health and Fitness Industry-Personal Trainer, Aerobic Instructor, Dietary Counselor, Assistant District
AerobicTrainer, Fitness Center Manager.
Progressed further into the Healthcare industry with expanding knowledge and education as well as experience
in just that-Long term care, Medical/Surgical/Rehab etc.
Education
St. Louis Board of Education School of Practical Nursing, St. Louis, MO
Vocational/Practical Nursing Diploma
Clinicals performed at; Shriner’s Hospital, Missouri Baptists Medical Center, Deaconess Hospital, Lutheran Medical Center Etc.
Ursuline Academy, Kirkwood, MO
High School/College preparatory studies
Affiliations Etc.
Mississippi Regional Valley Blood Bank 2008
Volunteer Blood Drive Coordinator
Featured guest on “St. Louis Community Matters” (St. Louis Metro Clear Channel Stations) 2008
Skills and Hobbies
Computer software/applications:
Power Point, Excel, MDI, Citrix, BBI, Windows, Microsoft office, InterQual, MCG, Outlook, PMMIS etc.
CPR and IV certified
Communication
Leadership
Writing
Traveling
Event planning/coordinating
Glasswork and Design
Kayaking
Charity Walk/Runs
Presenting/Corporate Training
References
Reference Name Contact Information
Denise Ladlie (Professional) 636-***-****
Nancy Nietzert (Professional) 314-***-****
Dr. Melissa Bean MD (Professional) 314-***-****
Dr. Fredrick W. Wagner MD (Personal) 314-***-****
Veronica Judd (Professional) 618-***-****
Liza Pequeno (Professional) 314-***-****
Tony Spielberg (Personal) 636-***-****
Laura Brooks (Professional) 636-***-****
Additional References Available Upon Request.
Contact this candidate