Registered Nurse Prior Authorization
Resume:
GINETTE SATURNE
Miami, Florida ***** 305-***-**** **********@*****.***
Professional Summary
Dependable Utilization Review Nurse promoting over 8 years of expertise in healthcare industry. Knowledgeable in admissions and stay reviews.
Skills
CMS guidelines, InterQual & Milliman (MCG)
Cerner, EMR/EHR
MedCompass, ATV, RUMBA, & ASD
Strong clinical judgment
Intensive care & Acute care expertise
Microsoft Office Suite
Quality Review, HIPAA, URAC, Medicare, Manage Care, CPT Code, ICD-9 & 10.
Documentation and reporting
Discharge planning coordination
Work History
Utilization Nurse Review Consultant-Post Acute Car 08/2021 to Current
CVS Health/Aetna – PA Market, PA
Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Performed admission reviews based for medical necessity based upon CMS guidelines and MCG criteria.
Submitted cases for criteria failures and helped facilitate resolutions and approvals.
Performed prior authorization review of services requiring notification.
Supervised and maintained all utilization review documentation through MedCompass.
Served as subject matter resource, providing information related to post-acute care situations.
Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Utilization Nurse Reviewer Consultant 03/2020 to 08/2021
Cognizant Technologies Solutions – Tampa, Florida
Inpatient, Post-Acute Care, Appeals, and Worker Compensation (For Aetna and Liberty Mutual)
Perform medical review assessment on utilization of health services (eg healthcare plans) in an accurate, efficient and timely manner while ensuring compliance with utilization management regulations and adherence to state and federal mandates
Reviews and evaluates complex clinical information related to the diagnosis, condition, treatment and timely utilization of health care services
Provide physicians and SMEs (Subject Matter Experts) with rationales based on reviews of medical records in order to determine denial or approval of care
Adhere to Medicare Guidelines and criteria during patients' medical reviews
Review provider appeals to ensure medical necessity and experimental/investigational claims were processed correctly according to multiple coverage guidelines
Make final determination based on findings and procedures within strict timelines established by regulatory requirements
Research provider appeals and evaluate medical documentation
Follow regulatory requirements, corporate values, policies, and procedures
Work with multiple processing systems such as INTERQUAL, QUICKBASE, ATV, and MCG
Utilization Review Nurse/UM Concurrent Reviewer 04/2019 to 12/2019
WellCare – Tampa, FL
Reviews medical information in order to determine the medical necessity of continued stay according to review standards
Determines whether treatments are consistent with member's diagnosis and appropriate level of care
Uses critical thinking to determine if treatments are consistent with member's diagnosis and clinical needs
Ensures services provided are within benefit plan and that appropriate contracted providers are utilized
Works with providers to obtain the information pertinent to evaluating treatment plan, medical necessity, appropriateness of care, timely progression of services and appropriate application of available benefits
Evaluates clinical information to identify and present cases during rounds
This includes identification of members at high risk for complicated medical treatment plans, readmissions potential, and admissions for potentially avoidable conditions
Reviewed patient admissions to determine medical necessity as directed by InterQual or Milliman (MCG) criteria
Determined medical necessity and cost-effectiveness of services through utilization review processes.
Registered Nurse, Seasonal 08/2017 to 04/2019
Advent Health North Pinellas – Tarpon Springs, FL
Provides direct quality care to a wide of variety of patients including daily monitoring, recording, and evaluating of medical conditions of up to 6 patients daily
Developed and direct a rotational system in managing the care of patients in the department
Interact and communicate with patients of all ages and ethnic backgrounds, giving quality medical care and treatment
Educate patient and families on new medications and newly diagnosis
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects
Administered medications, tracked dosages and documented patient conditions
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services
Trained and mentored new RNs on best practices, hospital policies and standards of care
Consistently assessed and evaluated patients' health needs by coordinating across medical disciplines to create, implement and modify personalized care plans.
Registered Nurse-Intensive Care Unit 01/2017 to 08/2018
Morton Plant North Bay Hospital – New Port Richey, FL
Manage and provides direct quality care of up to 2 patients in ICU and 3 to 4 in step-down unit based on acuity
Assisted physicians with beside procedures and treatment protocols
Worked as part of interdisciplinary team caring for critical patients
Managed life support equipment and IV administration of fluids and medications
Assist patients with basic care and change bedding
Respond to codes, stock supplies and report malfunctioning equipment
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services
Assessed patient health needs by reviewing and tracking EKG readings to address telemetry readings and quickly inform teammates on stability or acuity changes
Performed blood and blood product transfusions and intravenous infusions to address patient symptoms or underlying causes
Administered scheduled medications and therapies intravenously, rectally, orally, subcutaneously and via intramuscular injections while overseeing pain management plans
Monitored and managed various treatment and care interventions, including IV administration, wound and ostomy care and catheter insertion.
Registered Nurse 01/2016 to 01/2017
Morton Plant Hospital, Baycare Health System – FL
Treat injuries and illnesses that affect their patients' muscles or bones
Assessing patient statuses and notifying physicians of clinical changes
Responsible for providing an initial admissions evaluation of prospective orthopedics patients
Provide detailed information to patients about pre-operative and post-operative procedure status
Assist in pre-surgical procedure preparations and overseeing post-procedure recovery, (Telemetry/Medical Surgical)
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects
Administered medications, tracked dosages and documented patient conditions.
Registered Nurse 05/2015 to 12/2015
Physician Regional Hospital – Naples, FL
Provides direct quality care to a wide of variety of patients including daily monitoring, recording, and evaluating of medical conditions of up to 6 patients daily
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects
Administered medications, tracked dosages and documented patient conditions
Administered oral, intramuscular and IV medications to patients and monitored responses
Performed blood and blood product transfusions and intravenous infusions to address patient symptoms or underlying causes.
Registered Nurse 02/2014 to 04/2015
Advent Health Sebring – Sebring, FL
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects
Administered medications, tracked dosages and documented patient conditions
Administered scheduled medications and therapies intravenously, rectally, orally, subcutaneously and via intramuscular injections while overseeing pain management plans
Trained and mentored new RNs on best practices, hospital policies and standards of care
Conducted post-op reviews, tracked patients' vitals and monitored fluids to reach optimal care targets.
Education
Associate of Science 2013
Miami Dade College
Bachelor of Science: Business 2006
Florida A&M University
Certifications
Licensed Registered Nurse RN9371475 -2013
Basic Life support (BLS)-2021-2023
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