RN Utilization Review / Case Management
Resume:
Summary:
• Recent UR/CM experience: Exceeded company standard in productive billable time and ROI (return on investment)/Cost Savings.
Received bonus after first 6 months of employment.
• Engages in use of clinical Decision-Making criteria sets: InterQual / MCG’s, to meet medical necessity for approval or to forward to the Medical Director for review.
• Performs Initial and Concurrent reviews for safe appropriate timely discharge vs continued stay.
• Documents ongoing follow-up and monitoring of effectiveness of the interventions and reinforcing the treatment plan.
• Delegates patient care activities as appropriate; evaluates delegated activities for expected obtainable patient care outcomes.
• Uses systematic process and clinical skills to assess, plan, implement and evaluate an individual plan of care for a patient that
spans the continuum of care. The plan of care is developed in conjunction with the attending Provider, the patients and the
patient’s family or caregiver(s).
• Promotes patients' independence by establishing patient care goals and teaching patients and families to understand
conditions, medications, and self-care skills.
• 12 years Full-Time ED Staff RN level 1 Trauma & Emergency Center
Skills:
• Self-directed, successfully worked in previous remote positions.
TEAM participant
• Efficient and effective problem solver
• Organized. Professional verbal and written communication skills.
Advanced computer skills.
• Knowledge of Utilization Management and URAC/NCQA Standards
• Software applications include EPIC, Midas, MedHost, Cerner, MMOTS, FACETS, MAP 4.0, PC7
• Experience with Industry Standard Guidelines:
InterQual, Millimans, MCG’s, Evicore,
• Electronic uploads to MRIoA
• Knowledge of Value Based Care and effective transition of care.
• Experience with remote access VPN’s and use of multi software applications.
• Proficient with MS Office, MS Word, Excel, Webex, Zoom, Team mtgs.
• ER skills: Triage, Patient assessment, IV’s, Tubes, Pyxis, Medications.
• Patient Advocate with avid respect for continuity of care and thorough documentation
• Attentive listener
• Flexible toward change
• Prioritize well and am productive in an independent role
Certifications/Licenses:
• Unrestricted RN licensure -- eNLC State of FL (#9171141) Exp.Jul 2'22
Active NY (#523619) Exp. Jul 2024
• CCM Certified Case Manager from Commission for Case Manager Certification Exp. Aug 2024
• ACLS, BLS/AED from American Heart Association Exp. May 2022
Work Experience:
Utilization Review RN Change Healthcare, Remote position BCBSAZ HMO (TPA) July 2018 to Feb 2019
• Review of requests/clinical requiring pre-certification, for ex: high tech radiology, OP procedures, epidural/facet injections,
specialty medications.
• Engaging use of clinical Decision-Making criteria sets to meet medical necessity for approval or forward to the Medical
Director for review.
• Expert in use of Industry Standard Guidelines: InterQual, MCG’s, Milliman’s Care Guidelines, Evicore.
• Provided redirection assistance with Out of Network requests and engagement of Case Management.
• Review of DME and HH: skilled nursing visits, etc.
• Programs used: Facets, PC7, M3CC, Encoder, BCBS secure website, Skype IM, Web-Ex, Outlook 365, Biscom Secure File Transfer.
• Eligible for rehire. In good standing with employer.
RN Case Manager ER Santa Rosa Medical Center - Milton, FL July 2017 to May 2018
• Review of ER patients for proper admission status.
• Conducted Initial reviews to recommend Observation vs In-Patient status to the ER physician and PA’s.
• Evaluation of the patient’s clinical to meet medical necessity consistent with guidelines and specific plan payor criteria.
• Performed Concurrent reviews on Day 1 for timely discharge vs continued stay.
• Assisted with ER Social Service needs.
• Obtained bonus within the first 6 months of employment.
• Programs used: Med Host, Midas, InterQual, MAP 4.0, Right Fax. Knowledge of ICD 10 and DSM V.
• Eligible for rehire. In good standing with employer.
RN Case Manager (Short term contract) St. Elias Specialty Hospital-
Anchorage, AK Aug 2014 to Oct 2014
• Case manager for 50 bed LTAC.
• Assisted in management of patients toward safe, appropriate transitions of care and timely discharge.
• Used systematic process and clinical skills to assess, plan, implement and evaluate an individual plan of care for a patient that
spans the continuum of care. The plan of care is developed in conjunction with the attending Provider, the patients and the
patient’s family or caregiver(s).
• Maintains, updates and improves clinical expertise and care management skills.
• Provides appropriate education for patient, family and staff regarding community support systems.
• Documents ongoing follow-up and monitoring of effectiveness of the interventions and reinforce the treatment plan.
• Contributes to ongoing process improvement including related procedures, policies, patient support and documentation tools.
• Eligible for rehire. In good standing with employer.
Utilization Management -Remote position Conifer Health Solutions March 2012 to Nov 2013
• Utilization of a URAC certified, software application (MMOTS) to medically manage patients of In-patient & Behavioral
Health levels of care.
• Conducted Pre-service, Initial and Concurrent reviews of clinical information while applying Milliman Care Guidelines,
Interqual and other integrated research materials to meet medical necessity for admission; Authorize length of stay and
continued stay.
• The goal: to facilitate quality health care through the most cost-effective means, while meeting compliance of ERISA
timelines and HIPPA regulations.
• Collected pertinent clinical information for electronic uploads to Medical Review Institute of America for reviews that did
not meet criteria.
• Required self-directed learning and advanced computer skills.
• Exceeded the company standards with productive billable time and ROI/Cost Savings.
• Programs used: MMOTS, Outlook, Power Point, Citrix Go-to meetings.
• Eligible for rehire. In good standing with employer.
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