Utilization Review Manager Specialist

REBECCA DIXON

Pensacola, FL ***** 1-989-***-**** ***********@*****.*** WWW: Bold Profile

I have cared for patient's needs for many years with dedication and compassion. A hard working Registered Nurse (RN BSN) with progressive career history in direct patient,risk management grievances,case management, chart review and utilization review in Oncology, Med-surg and Psychiatric patients. Excellent planning and organizational skills are produced and facilitated . Retired briefly after a health issue which has resolved. Worked a temporary position for the COVID crisis after moving to Florida. The decision has been made to go back to a career full time for another 10 years in a remote position with a great company. I have learned that I am a nurse heart and soul. Promoting over 30 years of expertise in the healthcare industry both direct care and case management. Always there for my patients. Registered Nurse Cardiology, 09/2021 - 10/2022

Ascension – Pensacola, FL

Completed paperwork and prior authorizations and scheduled appointments for patients. Risk management functions by conducting risk management researching grievances by patients. Provided prompt accurate, detailed response in accordance with centers for medicare and medicaid. Observed and documented patient factors such as diets, physical activity levels and behaviors to understand conditions and effectively modify treatment plans. Communicated with healthcare team members to plan, implement and enhance treatment strategies. Evaluated patient histories, complaints, and current symptoms. Chart review/Quality review

Order entry with ICD code

Patient issue resolution with medications or scheduling for procedures. Regular contact with Pharmaceutical company for medication approval Registered Nurse, 03/2021 - 07/2021

Baptist Medical Center – Pensacola, FL

Covid clinic and urgent care prn/temporary position Conducted telephone triage to patient, family and significant others using nursing judgment according to protocol.

Complied with infection control policies and Personal Protective Equipment use in COVID-19. Complied with infectious disease measures to reduce spread of COVID-19 between patients, families and medical personnel.

Educated patients on COVID-19 symptoms and treatments. PROFESSIONAL SUMMARY

WORK HISTORY

Administered medications via intramuscular injections and monitored responses Registered Nurse, Direct Care/Case Manager Specialist, 03/2007 - 02/2018 MidMichigan Health – Midland, MI

Developed patient care plans, including assessments, evaluations and nursing diagnosis Identified patient care requirements by establishing personal rapport with patients and families. during interviews.

Risk management/ patient grievances

Case management/ utilization review

Quality review

ICD-9 and ICD-10 coding

CPT and HCPCS coding

Understanding of Medicare and health care guiding principles Chart review

Created patient assessments and plans for individual home care needs. Instructed patient and family on proper discharge care Equipped patients with tools and knowledge needed for speedy and sustained recovery. Performed admission reviews based for medical necessity based upon criteria. Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.

1 year Psychiatric unit

2 years ICU/CCU

3 years oncology floor administering chemotherapy and direct patient care 4 years medical surgical floor administering direct patient care and telemetry Participated in hospital committees to recommend quality improvement initiatives HIPAA compliance

Thorough documentation

Contributed substantially to successful department JCAHO accreditation by consistently operating to highest standards of care.

Assistant Director of Nursing, 01/2006 - 02/2007

Heartland – Bay City, MI

Quality review/case management/Utilization review

Established new policies and updated existing policies to improve standard of care for patients. Approved recruitment, hiring and orientation of new nursing staff. Directed management team meetings.

Complaints, grievances and medicare/medicaid compliance Pharmacy reviews of medications

MDS coordinator utilizing ICD 10 codes

Verified prompt and accurate completion of MDS activities for billing. Complied with federal and state regulations for completion and coordination of RAI process. Created and maintained facility documents and records Completed initial assessments of patients and family to determine and address individual home care needs, Re-evaluations as needed to revise needs.

Reviewed missing assessment reports and analyzed issues for leadership team. RN Owner/Home Health Patient Care Provider, 05/1994 - 02/2007 RM Nursing – Midland, MI

Contract with Medicaid

Home health care placement recommendations according to needs Telehealth

OBRA Assessments/MRDD population/Behavior health/dual diagnosis Communicated with insurance providers to resolve denied claims and resubmitted. Filed and updated patient information and medical records. Prepared billing statements for patients and verified correct ICD 10 coding. Liaison between patients, insurance companies and billing office. Developed and updated policies and procedures, maintaining compliance with statutory, regulatory and local, state and federal guidelines relating to HIPAA, benefits administration and general liability. Implemented successful healthcare program through professionalism, quality of care, medical teaching and patient satisfaction.

Informed physicians of any changes to patients' health or concerns observed during home visits. Provided physical assessments, medication and chronic disease management to home health patients. Case management

Managed exceptional care from admission to discharge. Bachelor of Science: Nursing, 01/2018

Chamberlain University - Downers Grove, IL

GPA 4.0

Certification: Telemetry, 04/2010

Saginaw Valley State University - Bay City, MI

Associate of Applied Science: Nursing, 01/1993

Davenport University - Grand Rapids, MI

GPA4.0

summa cum laude graduate

RN BSN

Fl. licensed- Expires: August 2024 Florida

EDUCATION

ACCOMPLISHMENTS

Home Care (10+ years)

EMR Systems (10+ years)

Oncology (6+ years)

Neurology (2+ years)

Telemetry (7+ years)

Behavior Health (14years)

Clinical Experience(10+yrs)

Nurse Management (10+ years)

Case Management (10+ years)

Medical Records/ Review/Utilization review(2 yrs)

Analysis skills

BLS Certification

RN BSN

Telemetry certification

Microsoft PowerPoint/ Outlook/Office/Excel

CPT Coding

Preauthorizations

Chart review for errors

Risk management

Case management

Insurance Eligibility

Utilization Review

EMR Systems

Staff Training

Setting Up Referrals

HIPAA Education

Documentation Requirements

Case Conferences

Follow-Up Care Coordination

Discharge Coordination

CERTIFICATIONS

SKILLS

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