Beaumont Hospital Review Nurse
Resume:
TRACIE SMITH
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PROFESSIONAL SUMMARY
I have been a Registered Nurse for 25 years and have gained a wellspring of knowledge and wisdom in the healthcare field. My years of experience have facilitated a skilled maturity as a Registered Nurse proficient in care of postpartum, pediatric, medical surgical patients, and post-operative care of surgical patients. In 2017 I transitioned from the hospital to a Medicaid Managed Plan as a Utilization Review Nurse. My Job responsibilities were to process prior authorization request for inpatient hospital admissions and outpatient services. As the lead utilization review nurse, I was responsible for training new employees as well as delegate duties to the team. I also worked closely with the Medical Director to evaluate outpatient services and inpatient admissions for medical necessity. SKILLS
Process prior authorization request for inpatient
admits, skilled nursing facilities, inpatient rehab and outpatient services
Process concurrent reviews for inpatient admits
and skilled nursing facilitates
Utilize InterQual Criteria to assess for Medical
Necessity
Proficient at utilizing the Medicaid Fee Schedule, the Medicaid Provider Manual and Champs to
assess covered benefits
Process dis-enrollments for ineligible members
Process denial of services
WORK HISTORY
10/2017 - 12/2019
Utilization Review Nurse
Trusted health Plan - Detroit, MI
Applied medical criteria and clinical judgment to prior authorization requests to evaluate and make determinations for Inpatient hospital admits, surgeries/procedures, medications, and preventative diagnostic testing
Referred cases to secondary review for failure to meet medical criteria Processed disenrollments for members who are determined ineligible for the medical plan Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries
Determined medical necessity and cost-effectiveness of services through utilization review processes Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria
Process Denials for medical necessity or unable to meet medical criteria 05/2006 - 10/2017
Med-Surg/ Maternal Child/Pediatrics/Postpartum Registered Nurse Beaumont Health-Bostford Hospital - 28050 Grand River Ave, Farmington Hills, MI 48336 Responsibilities:
Document all patient assessments, vital signs, nursing notes, nursing diagnosis/care plans in Beaumont hospitals electronic documentation system Epic Manage care for post-operative patients from admission through discharge Perform physical assessments and nursing care of newborns and infants Assist physicians with minor surgeries and non-invasive procedures Report to MD and initiated appropriate interventions by reading and interpreting external fetal monitoring strips
Delegate duties to ancillary staff
Liaison between patients/family and physicians to ensure comprehension of treatment plans, 21661 Church Street, Oak Park, MI 48237 248-***-**** *************@*****.*** procedures, and discharge care
Effective education on disease management, medication purpose/side effects and health maintenance
Ensure superior patient hospital experience by addressing patient concerns, demonstrating empathy, and problem resolution
06/1998 - 05/2006
Registered Nurse-Postpartum / Antepartum
Providence Park Hospital, Southfield Campus - 16001 W Nine Mile rd, Southfield MI 48075 Responsibilities:
Complete care of the postpartum, antepartum, and gynecological patients Managed care of post-operative c-section patients from admission to discharge Counseled and educated patients about reproductive health issues and wellness Educated patient/family on proper maternal and infant care after discharge EDUCATION
1993
Bachelor of Science: Nursing
Oakland University - Rochester Hills, MI
CERTIFICATIONS
CPR/BLS Certification
REFERENCES
Kinga Rudnicki RN
Medical Director Medicaid-HAP
Sheila M. Clay RN-BSN, NP
Nurse Practitioner
Sheila Hazley
Assistant Manager- Burlington Coat Factory
ACCOMPLISHMENTS
Patient Care:
Nominated for 3 Daisy Awards bypatients for delivering compassionate care that exceeded hospital requirements.
Received an Applause letter from a patient that was announced in the Beaumont hospital employee newsletter.
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