Customer Service Utilization Review

Susan Pierce

Qualification Profile

adw3oz@r.postjobfree.com • 413-***-****

LinkedIn • Easthampton, MA 01027

Performance-focused and accomplished professional with extensive experience in reviewing clinical information and applying evidence-based practice to achieve best outcomes for patient-centered care. Proficient in collaborating with physicians and other healthcare providers to determine best course of treatment for patients. Well-versed in providing best care to patients, managing staff, and overseeing daily operations of unit. Demonstrated excellence in coordinating with insurance companies and other payers to ensure suitable coverage for patient care. Instrumental in developing and implementing care plans to deliver continuous care and safe transitions. Stellar record of participating in quality improvement initiatives and process improvement projects to enhance effectiveness of utilization management operations. Proven success in managing all aspects of emergency department and care continuum department.

Areas of Expertise

Emergency Management Department

Case Management Department

Real Time Utilization Review

Patient Assessment & Supervision

Bed Management

Care & Discharge Planning

Process Optimization

Compliance Management

Staffing & Scheduling

Insurance Reviews & Support

Utilization Management

Problem Identification & Resolution

Professional Experience

Cooley Dickinson Hospital, Northampton, MA Aug 2022 – Present

Nurse Manager Care Continuum

Maintain on-time reimbursement and appropriate level of care for patients by facilitating Medicare appeals, customer service, and interactions with insurances. Manage staff scheduling, performance reviews, and educational needs to ensure compliance with regulatory requirements. Conduct chart audits and provide accountability in aligned with clinical guidelines and regulatory standards. Serve as liaison across patients, families, and healthcare providers to sustain effective communication and collaboration.

●Ensured high quality patient care and effective patient throughput by administering oversight of case managers, utilization review (UR), and social work teams.

●Optimized compliance with key regulations from 20% to 90% over six months by developing and implementing education plan for staff.

●Developed and implemented performance improvement for case management department with impressive results.

Cooley Dickinson Hospital, Northampton, MA Mar 2022 – Aug 2022

RN Case Manager

Conducted comprehensive patient assessments and developed individualized discharge plans to meet GMLOS and LOS targets. Collaborated with healthcare team members to deliver medical care in efficient manner. Managed Medicare appeals process to assure appropriate coverage for services rendered. Delivered effective customer service to patients and families by responding to inquiries and addressing concerns.

●Developed and implemented discharge plans, while considering patients' health status, care needs, and insurance guidelines.

●Maintained fiscal responsibility by coordinating with healthcare team, assuring suitable utilization of resources, and avoiding unnecessary costs or delays.

Cooley Dickinson Hospital, Northampton, MA Oct 2019 – Mar 2022

Nurse Manager, Emergency Department

Oversaw daily operations, including troubleshooting issues, monitoring quality metrics, and identifying areas for improvement. Developed new processes and policies related to patient care and safety. Conducted pharmacy reviews for narcotic administration monitoring to assure safe and proper medication use. Investigated and resolved incident reports, service recovery, and patient complaints.

●Supported 24-hour oversight and ensured safe staffing of 26-bed emergency department, while managing team of 90 staff members.

●Maintained compliance with regulatory requirements and accreditation standards by developing and directing strategic policies and procedures.

●Led effective management during multiple COVID surges and flow process changes.

Cooley Dickinson Hospital, Northampton, MA Aug 2017 – Oct 2019

Emergency Department Nurse

Assessed and managed patients across lifespan with various acute illnesses and injuries. Implemented critical thinking skills to prioritize care based on acuity and severity. Collaborated with interdisciplinary teams, including physicians, respiratory therapists, pharmacists, and social workers to supervise optimal patient outcomes and discharge planning.

●Delivered excellent patient care in fast-paced environment by guiding and supervising junior nurses, while coordinating as charge RN and preceptor.

Mercy Medical Center, Springfield, MA Sep 2007 – Sep 2017

Clinical Care Coordinator

Supervised efficient staffing and scheduling for nurses and assistants across hospital to ensure adequate coverage and patient care. Conducted case management to deliver best-in-class patient care and services, including follow-up appointments and referrals. Performed real-time utilization review to evaluate medical necessity and effectiveness of key services. Executed insurance reviews to lead end-to-end coverage of patients’ healthcare needs. Analyzed psychiatric intakes for admissions to maintain high level of care and treatment plans. Monitored length of stay for inpatient units and facilitated appropriate discharge planning and care transitions to improve patient outcomes and reduce costs. Led process improvement studies to identify areas for improvement and deliver effective solutions. Assisted with federal grant application and implementation to support hospital operations and patient care.

●Supported needs of patients and staff, while managing 40-bed Emergency Department.

●Maximized patient flow and throughput within hospital by managing bed availability and placements.

●Introduced ICD10 coding for admitted patients, while ensuring accurate medical record documentation and billing.

Additional Experience

Clinical Manager, Heritage Hall West, Agawam, MA (2006 – 2007)

RN Emergency Room Nurse, Holyoke Medical Center, MA (2005 – 2006)

RN Emergency Department, Baystate Medical Center: Springfield, MA (2002 – 2005)

Nursing Supervisor (LPN), Commonwealth Registry of Nurses (1993 – 2001)

Education

Bachelor of Science in Nursing

Bay Path University, Longmeadow, MA (2018)

Associate Degree in Nursing

Holyoke Community College, Holyoke, MA (2004)

Licensed Practical Nurse

Dean Vocational High School, Holyoke, MA (1990)

Technical Proficiencies

MIDAS 3M ICD10 Codes CQI InterQual EMR (EPIC, Meditech, Allscripts) UKG KRONOS

Licenses & Certifications

Registered Nurse (MA) #RN260401 BLS ACLS PALS ENPC

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