Utilization Management
Resume:
Kim Milbourne, RN, MHS, MBA
**************@*****.***
Professional Experience
**/**** ** ******* *********** Management Nurse, at
Independence Blue Cross
Utilization reviews of Emergency /Urgent care cases in order to render a determinations for inpatient medical care. Assure reviews meet Interqual Criteria/IBC or CMS criteria for inpatient level of care . Other responsibilities include but not limited to data abstraction, write up reviews, communicate with senior nurses, managers, and medical directors for authorization and coordination of services.
6/13/16 to 6/6/17
Cigna Health Springs
Utilization Review Nurse
Retrospective and precertification review of ambulance, physical, occupational, speech, social work, home health aide, and documentation for compliance in accordance with CMS standards and Cigna Organization Policy to meet approval for authorization of services
Review therapy and home health claims, physician, inpatient and outpatient acute and ambulatory, medical record review for clinical content, to meet Interqual and Millenium Criteria.
6/2015 to Present - Per Diem Nurse Supervisor at
General Healthcare Resources at Long Term Care Facilities Duties: Documentation on electronic medical record, Medication administration, assessment, planning, implementation and evaluation of care.
RNAC at a Long-Term Care Facilities
Complete MDSs, clinical medical record review for clinical content, verify correct coding for billing submissions, medical record submissions to CMS, update care plans, insurance verifications, Utilization Review, Case Management
Jennersville Home Health
Home Health RN
Complete the OASIS, admit patients to home health services, complete start of care, assess the patient, wound care, diabetic teaching and monitoring, respiratory assessment and management, mini nebs, teaching for new diabetics, wound care, medication prefill, teaching patients injections, catheter care IV medication administration, and after care following surgical procedures, wound care post op surgical care
2003- 11/2014
Genesis Health Care and Genesis Staffing, Kennett Square, PA,
Clinical Registered Nurse Supervisor (part time & per diem)
Long term care, nurse supervisor, medications,assessment, planning, implementation and evaluation of care supervision of nurses, nursing assistants, ancillary staff, collaborate with physicians, update care plans and medical records
Reimbursement Coordinator
MDS Minimum Data Sets, collect data from documentation and code the data for Medicaid, Medicare and private insurance billing
Staff education on proper coding, financial reports, trending and analysis, scheduling and record keeping (PPS trackers)
12/2011 - 7/2014
Connolly /Now Cotiviti HealthCare, PA,
Clinical Reimbursement Auditor
MS-DRG, ICD-9 coding auditing, recovery auditing of provider charts, MDS RUG level reviews, appeals, and quality assurance, software: McKesson, 3M
Concept development for RUGs and Home Health, application of InterQual, Millinium and CMS guidelines, education and training
2/2010 - 10/2011
Bryn Mawr Terrace, PA
Director of Clinical Reimbursement/RNAC
Monthly clinical reimbursement reports, oversee Medicaid and Medicare end of month billing, picture date billing process, trending analysis reports, Utilization Review
Supervision of 5 clinical reimbursement coordinators and two buildings, department budget management, CMS submissions
2010 – 2011
Towne Manor East Norristown, PA
Clinical Reimbursement Consultant
MDS auditing and audit weekly MDS submissions and in-service education
Monthly clinical reimbursement reports, Medicaid and Medicare end of month billing, picture date billing process, trending analysis reports and the monitoring of four buildings, oversea CMS submissions
2000-2002
Presbyterian Health Center, PA
Staff RN
Nurse supervisor, clinical nursing, supervise staff, patient care
1998 – 1999
Evangelical Manor Nursing Home, PA
Director of Nursing
Management & supervision, quality assurance, planning and implementation of programs, development of policies & procedures, utilization review, staffing, managing and maintaining the nursing budgeting, staff counseling
1995-1998
Universal Consulting & Counseling Services, Inc., PA
Quality Assurance Nurse
Oversee all quality assurance functions, quality assurance audits, Medicare & utilization review audits, update policies, and procedures, quality assurance in-service education
Contract Assignment
Quality assurance, utilization review using Interqual Criteria, credentialing and case management at HMA, BCBS and Jefferson University Hospital
1994-1995
Multi-Care Nursing Homes, NJ
Regional Nurse Consultant
Chart audits, regulatory compliance audits, in-service education, quality assurance audits, Medicare & utilization review audits, update policy & procedure, in-service education, substitute DON
1990-1998
Home Staff Services/Kids Staff, PA
(P/T, W/E & Holidays)
Home Health Nurse
Private duty nursing in patients home, wound care, respiratory, diabetic teaching and monitoring, medication management and prefill, Foley catheter insertions and maintenance, JP drains, IVs, injections, tube feedings, bolus feeds, Lovenox and B12, as well as insulin injections. Assessment, planning, implementation and evaluation of care, start of care, admissions, discharges.
1999 -2002
Member of Maple Village Board of Directors, Hatfield, PA
Education
1999-2002 University of Maryland, University College, Adelphi, MD
Major: Business
Masters Degree in Business Administration
1989-1990 Pre Masters Program
1990 to 1992 Masters Program in Human Services at Lincoln University, in Lincoln University PA
Masters Degree in Human Services
1984-1988 Wesley College, Dover, DE
Major: Nursing
Associates Degree in Science of Nursing
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