Authorization Representative Clinical Reviewer

Darrolyn D Wilds

Tampa, FL

LPN License No: PN***4698 (07/31/2023)

Recruiter Summary:

Darrolyn holds a Multistate LVN license in the state of FL and has over 10 years of experience working into Utilization Management and case management with different healthcare setting.

Has experience working with Utilization management, case management, prior authorization, health risk management, disease management, HEDIS, Medical Billing, ICD-10 and used InterQual/Milliman criteria for clinical reviews.

Performed telephonic pre-authorization of procedures, utilized clinical skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.

Utilized CMS to review, update and manage healthcare plans, coverage, benefits, and other patient data.

Responsible for reviewing clinical information against InterQual/Milliman Robertson guidelines, along with corporate policies, and determining whether services can be approved or if they would need to be reviewed per guidelines via Medical Director.

Education:

St. Petersburg College - Saint Petersburg, FL Associate in Arts in Business February 2020.

Skills:

Managed Care

Utilization Review/Utilization Management

Patient Care

Management

HEDIS

Hospice Care

Counseling/Therapy

Documentation

Case Management

Microsoft Office/Outlook/Excel/ Word

Medical Records

Medication Administration

ICD-10

Critical Care Experience

Anatomy Knowledge

Insurance Verification

Supervising Experience

Medical Terminology

Epic/EMR Systems

Professional Experience:

EviCore (Cigna)- Different States Temp. Aug 22-to Nov 22

•

Utilization reviews in accordance with federal and state regulations.

•

Perform UM reviews of medical records and clinical documentation to determine medical necessity

iCare Health Network - Tampa, FL Sept 21 to Apr 22

Utilization Review Nurse

Utilization reviews in accordance with federal and state regulations.

Perform UM reviews of medical records and clinical documentation to determine medical necessity for ophthalmology services according to NCD / LCD and Health Plan criteria.

Request additional documentation as needed.

Releases utilization management determinations to stakeholders following health plan, regulatory and internal established guidelines.

Work closely with management team in the ongoing development and implementation of utilization management programs.

Adheres to quality standards and UM guidelines.

Proper documentation and maintenance of records in proprietary software is required.

Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocol.

Habana Health Care Center, FL Nov 21- May 22

LTC Registered Nurse

Responsible and coordinators overall interventions of patients with behavioral issues and chronic diseases.

Care Centrix (Aerotek agency)- Tampa, FL Apr 20 to Aug 21

Clinical Reviewer

Ability to work independently under general instructions and with a team

Intermediate to advanced computer skills and experience with Microsoft Word, Excel, and Outlook.

Performed telephonic pre-authorization of procedures, utilized clinical skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.

Responsible for reviewing clinical information against InterQual/Milliman Robertson guidelines, along with corporate policies, and determining whether services can be approved or if they would need to be reviewed per guidelines via Medical Director.

Tampa Family Health Centers - Tampa, FL Jul 19 to Apr 20

Case Manager

Responsible and coordinators overall interventions of patients with behavioral issues and chronic diseases.

Conduct telephonic contact with patients with chronic issues.

Ensure systemic use of Health Risk Assessment for patients deem for coordination of care.

Conduct in person visits if needed.

Establish a follow up schedule for patients and monitor patient progress using an electronic care management tracking system.

Home Health Nurse Greystone Healthcare - Tampa, FL Mar 18 to Mar 19

LPN

home health visits wound care

Bp checks

Favorite Agency Staff Nursing - Tampa, FL May 17 to Mar 19

LPN on the Assignment (agency job)

Performed Clinical Nursing on Med Sur floors at Medical Centers in Tampa

Ensured proper patient monitoring and follow up.

Health integrated - Tampa, FL Apr 16 to May 17

LPN Utilization Case Manager Coordinator

Conducted telephonic pre-authorization of procedures, utilized clinical skills to support the coordination, documentation, and communication of medical services and/or benefit administration.

Change Healthcare - Atlanta, GA Feb 16 to May 17

HEDIS LPN (Remote seasonal)

Performed quality measures for pediatrics; measured injections and ensured injections were up to date with HEDIS and reviewed charts to ensure compliance.

Documented, updated and verified patient documentation for yearly compliance with HEDIS.

Updated HEDIS charts and ensured doctor's office/clinical are following HEDIS.

Contacted Medicaid and Medicare insurance to verify the inpatient healthcare plan and identify any care gaps.

Reviewed shot records for infants to adolescents to verify compliance with HEDIS.

Utilized CMS to review, update and manage healthcare plans, coverage, benefits, and other patient data.

Consulate Health Care - Brandon, FL Feb 16 to May 16

LPN-Floor Nurse

Distributed medications to patients in a timely matter.

Performed Initial patient assessments.

Provided clinical related information and evaluated patient clinical needs for specific therapies that treat chronic disease.

Ensured continuity of care by verifying, collecting, analyzing, organizing and reviewing patient data, medical histories, and evaluating, instructing, problem solving, according to specific plans.

Worked with dialysis, GT tube, wound care and hospice patients.

IASIS - Tampa, FL Nov 14 to Jan 16

Prior Authorization LPN

Conducted telephonic pre-authorization of procedures, utilized clinical skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.

Thorough and professional clinical knowledge with claims from EMR to Medical Director for approval of special cases InterQual/Milliman Robertson guidelines and MedSolutions plus Humana medical coverage policy Medicare.

Handled incoming calls, toggling between screens to access information, Microsoft efficient and assisted providers with tracking authorization.

Use of spread sheets and word programming.

Aetna - Tampa, FL Apr 13 to Nov 14

Prior Authorization LPN

Performed telephonic pre-authorization of procedures, utilized clinical skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.

Responsible for reviewing clinical information against InterQual/Milliman Robertson guidelines, along with corporate policies, and determining whether services can be approved or if they would need to be reviewed per guidelines via Medical Director.

SNP Health integrated - Tampa, FL May 2012 to April 2013

Case Manager

Worked for inpatient and outpatient, utilized clinical skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations.

Adhered to InterQual medical guidelines; medical coverage policy Retro- authorization nurse and claims denial Critical competencies include flexibility, professionalism, as well as clinical knowledge with claims.

Handled inbound calls for providers with questions on authorizations and approvals.

Processed appeals and claims for inpatient and outpatient authorizations for Medicare and Medicaid providers

Case Manager: Special needs program Conduct telephonic contact with patients identified with chronic and complex care needs

Ensure systematic use of an initial Health Risk Assessment (HRA) for patients deemed eligible for care coordination

Special needs coordinator; building care plans on patients in the disease process and patients behavioral health needs.

Care coordinator Pre-Authorization Nurse and (LPN Subject matter expert).

Amerigroup/Anthem - Tampa, FL Oct 09 to May 12

Prior Authorization Representative

Monitored inpatient, outpatient, and Skilled Nursing Facility patients and initiate patient care arrangements.

Reported findings to Medical Management, Medical Director, and Center Administrator.

Responsible for patient care management to assure appropriate care is provided; reinforced patient education regarding preventative care, dietary restrictions, medications, and other therapeutic regimens; coordinate home health and DME requests and provided recommendations to the Medical Director.

Provided oversight in patient care evaluation, coordinated the collaboration of the Primary Care Providers and Consultants, and made suggestions to improve plans to meet patient needs.

Assisted with the monitoring of utilization management and making recommendations regarding effectiveness of health care resources, trending, and intervention.

Assisted in the assessment of clinic operations and made recommendations as necessary. Educated team with answering questions and providing additional insight on clinical operations.

Contact this candidate