Nurse Utilization Manager

CINDY HARRISON RN, CCM

**** ******* ***** ****, ********, TN 37721 (C) 865-***-**** ************@*******.***

Professional Summary

Registered Nurse with solid management, case management, utilization management and clinical experience within a managed

care environment. Experience with onsite and remote management, case management and utilization review within hospitals and insurance companies. Detail oriented and quality focused towards meeting high quality, efficient work outcomes. Focused on meeting the needs of members. Experience with multiple plans and medical necessity guidelines. Great computer skills.

5 years of Management Experience Adept at prioritizing/managing deadlines

15 years of Discharge Planning Experience ICD-10 and CPT Knowledge

Acute Care Expertise Patient and family advocacy

Trained in Value Based Leadership Interqual and Milliman Care Guideline; CMS

High level of autonomy guidelines; TennCare rules; NIOSH TGD/MCD

Patient/family focused Self-starter

Patient evaluation/intervention Team player

High Problem resolution capability Trained in United Operations Model

Trained in Customer Service Experience with multiple software

Work History

Commonwealth Care Alliance (CCA)

Long-Term Service and Support (LTSS) Utilization Management RN 12/2021-Present

Team member of the LTSS Utilization Management team reviewing initial authorizations, reauthorizations and continuation of service requests for LTSS services: Personal Care Agency, Homemaker, Adult Foster Care, Group Adult Foster Care, Assisted Living Services, Adult Day Health, Day Habilitation, Laundry and Home Delivered Meals. MassHealth and CCA Medical Necessity Guidelines used to conducted medical necessity reviews. MDS, LTSC/GSSC Assessments and TFTT reviewed for supporting clinical documentation of the medical necessity guidelines. Collaboration with CCA Care Team and Medical Directors for any adverse determinations to prevent under or overutilization of member’s needs.

United Healthcare Group

Assistant Manager Utilization Management 07/2021-10/2021

UHG Optum Serve, Logistic Health Inc.(LHI) World Trade Center Health Program

Opportunity for promotion within UHC for an assist manager position to service the survivors and responders of 9-11 events.

Assistant Manager with direct report of 8 RN Utilization Management/Prior Authorization Nurses, 2 RN Exam Review Nurses, Administrative Associate and Supervisor of Certification Specialist. Indirect report of 10 nonclinical Certification Specialists. LHI contract for health plan is pending renewal with National Institute of Occupation Health and Safety (NIOSH). LHI lost request for proposal for renewing NIOSH contract.

Nurse Utilization Management Private Duty Nursing

UHC TN Community and State PDN Program 01/2019-07/2021

Perform utilization review for medical necessity of private duty nursing services for the TennCare members. Work with PDN Case Mangers and Medical Directors to meet the needs of the fragile health needs of our members for purpose of skilled and unskilled private duty home care needs. Medical necessity review based on TennCare rule and benefits. Participate in bi-weekly interdisciplinary rounds. Collaborate with Agencies, Leadership, Care Coordinators, Case Managers, Medical Directors and internal Departments for purpose of problem solving and addressing the needs of our members. Developed Agency Transfer Spreadsheet to assist with efficiency of workflow and avoiding liquidate damages. Developed spreadsheet to capture UM annual savings based on reductions (September 2020-Mid March 2021 $2,508,343.00.)

Nurse Utilization Management Inpatient

Anthem Amerigroup – Telecommuting TN 09/2017-01/2019

Performing acute inpatient utilization management reviews for medical necessity. Working with the Amerigroup team for discharge planning. Identify and coordinate care needs for member with appropriate case management following, long term care services referrals and other Amerigroup post-acute care programs. Participate in weekly Medical Director Rounds, reporting on case medical and discharge barriers. Working with hospital Case Managers and Social Workers to assist with discharge barriers.

Supervisor Utilization Management Prior Authorization

United Healthcare (UHC) Military and Veterans – Telecommuting TN 07/2016-9/2017

Supervisor duties for 18 nonexempt Utilization Review Nurses performing outpatient and inpatient preauthorization reviews. Trained and utilized the United Operations Model for monitoring team’s daily efficiency, utilization and productivity. Lead daily team huddles, perform monthly one on one with staff and coaching as needed to keep telecommuting team engaged and accountable. Attend and participate in committees to address system, auditing, IEP, adjunctive dental and genetic process improvements. United Operations Model (UOM) metrics monitored daily and met and exceeded metrics monthly. UHC lost request for proposal renewing contract with department of defense.

Supervisor Provider Appeals and Denials 11/2015-07/2016

BlueCross BlueShield of TN – 1 Cameron Hill, Chattanooga TN

Supervisor of Medicare Advantage appeals and denials nursing analysts. Supervising a team of 5 registered nurses analyzing appeals and denial letters. Development of denial templates and cross training of department staff to decrease department turn-around time. Developed spreadsheets for tracking of monthly staff productivity, quality and goals for monthly one on ones with staff. Developed a daily spreadsheet for staff assignments and tracking of turn-around time. Developed opportunity grid for identifying errors found within utilization review prior to appeals

and denial reviews.

Case Management Acute Inpatient Care 02/2015-11/2015

Community Health Alliance (CHA) – 445 S. Gay Street, Knoxville TN

Case Management for Market Place Members. Responsible for managing acute inpatient care from day of notification through discharge. Used Milliman Care Guidelines. Assisted hospital case managers and discharge planners with meeting anticipated length of stay and discharge plans to lessen readmission risks. Reviewed clinical for meeting medical necessity of outpatient services and durable medical equipment. Used LCD/NCD and NCCN medical guidelines. Collaborated with transition of care and chronic case management for meeting members’ ongoing healthcare needs. CHA voluntarily left the Marketplace Consumer Operated and Oriented Plan (CO-OP) under the Affordable Care Act.

Acute Care Coordinator/High Risk Case Manager 05/2010 to 09/2014

United Healthcare Group – 2035 Lakeside Drive, Knoxville TN

High Risk Case Manager - Performed High Risk Case Management to deliver holistic, consumer-centered,

continuous care with a focus on preventive care and improved self-management. Provided targeted case

management for those most frail and vulnerable consumers with complex and co-morbid conditions

within the United Healthcare Community and State membership. Performed telephonic and field case

management. Acute Care Coordinator - Worked with the Acute Inpatient Care Team and Medical Director. Performed acute care reviews for initial, concurrent and retrospective reviews. Worked remotely via right fax and telephonic to perform medical reviews and discharge planning. Utilized Milliman Criteria Guidelines. Proficient with Microsoft Office, Facets, CareOne and WebEx.

Education

Associate of Science: Nursing1991

Southern College of Seventh Day Adventist - Orlando, FL

Magna Cum Laude

Certifications

Registered Nursing since 1991 (Tennessee and Massachusetts Licenses)

Certified Case Manager since 1996

Graduate of Critical Care Nursing Internship Program 1991

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