Review Nurse Utilization

Sarah C. Fernkas, LPN, Utilization Review Nurse

***** ******** ***** #*** **********, Kentucky 40299 502-***-**** advov1@r.postjobfree.com

Driven healthcare professional with an exemplary record of experience as a utilization review nurse, clinical advisor, financial case manager, and licensed practical nurse. Proactive leadership style with a focus on empowering staff to successfully perform their roles. Applies independent judgement to complex situations requiring quick action. Collaborates effectively with other healthcare staff to improve procedures. Talent for allocating medical resources and balancing fiscal needs with provision of excellent patient care. Key strengths include…

Utilization Review

Staff Leadership

Team Collaboration

Admission & Discharge

Obtaining Precertification

CMS,MCG & Interqual criteria

Data Collection & Analysis

Policy Compliance

Process Improvement

PROFESSIONAL EXPERIENCE

Valenz Healthcare, Louisville KY 2022- present

Utilization Review Nurse 2

Manage precertification/concurrent and retro reviews for medical/surgical Inpatient, Psych, IOP, PHP, Residential for Behavioral Health and Substance Abuse.

Manage/process precert/concurrent/retro reviews for OP surgery, DME, Injections, Infusions, Pain Management, home heath, therapies using MCG and Nursing Judgement.

Refer to Medical Director if Guidelines not met.

Evolent/Passport/Molina, Louisville, KY 2019-2022

Utilization Review Nurse, Medicaid.

. Managed precertification of acute inpatient admissions, outpatient medical procedures, Pain management, home health, medical coding such as J CODES, DME CODES in accordance with company guidelines and nursing judgement.

. Streamline the review process within the framework of additional monitoring activities.

. Mostly used Interqual criteria, until recently changing to MCG criteria.

. Collaborate with physician advisers to support policy development and process improvement.

. Document transcription orders, treatments provided, and support overall medical plan.

. Send cases to Medical Director for review of cases that do not meet criteria. Set up peer to peer if needed. Created denial letters in accordance with company policy and physician documentation.

. Processed retro cases.

Central State Hospital, Louisville, KY 2017 –2019

Lead Utilization Review Nurse

Integrate clinical knowledge with billing knowledge to review initial and concurrent reviews, set up peer to peers if needed then evaluate and appeal clinical denials that are related to the care provided to the hospitalized patient.

Ensure appropriate admission and discharge procedures in accordance with regulations.

Streamline the review process within the framework of additional monitoring activities.

Collaborate with physician advisers to support policy development and process improvement.

Engage directly with external reviewers and agencies at the state and federal level.

Document transcription orders, treatments provided, and support overall medical plan.

Complete cross-training with medical clinic, and employee health and infection prevention.

Humana, Louisville, KY 2008 – 2017

Utilization Review Nurse, Clinical Advisor, Medicare (2010 – 2017)

Consistently exceeded expectations regarding volume of cases required to be executed each day.

Executed precertification for initial reviews and concurrent reviews for inpatient skilled nursing care admissions based on medical necessity. Set up peer to peers if I was unable to approve. Created denial letters in accordance with company policy and physician documentation.

Coordinated effectively with providers to obtain the required information in a timely manner.

Identified services that weren’t warranted, and recommended appropriate level of care for member.

Communicated with the regional medical director when the provider declined to re-evaluate.

Analyzed information gathered by investigations and reported findings and recommendations

Audited and analyzed patient records to ensure quality patient care and appropriateness of services.

Nurse Clinical Advisor, Commercial (2008 – 2010)

Managed precertification of acute inpatient admissions, outpatient medical procedures, home health, medical coding such as J CODES, DME CODES in accordance with company guidelines and nursing judgement.

Served as primary nurse over mental health inpatient admissions for UK HMO network and HumanaOne.

Collaborated with other health professionals to ensure treatment aligned with medical coverage plans.

Curascript Infusion Pharmacy 2006 – 2007

Financial Case Manager

Obtained precertification from various commercial insurance companies for infusion services such as J CODES.

Visiting Nurse Association 2005 – 2006

Central Intake Coordinator, LPN

Processed referrals and verbal orders, and educated VNA services to patients and potential clients.

Enabled efficiency and productivity of operations by providing support to staff within the department.

Spectracare, Inc.—Financial Case Manager, LPN, Utilization Case Manager, LPN 2004 – 2005

National Health Services—Medical/Claims Review Nurse 2001 – 2004

EDUCATION & CREDENTIALS

Practical Nurse Program Diploma, Kentucky Tech-Jefferson Campus

Undergraduate Studies, Jefferson Community College

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