**** ****** ** (Unit- ***) Phone: 512-***-****

Austin, TX 78748 Email: adwp3a@r.postjobfree.com Lisa A. Hamilton

Qualifications Summary

A seasoned highly-skilled Registered Nurse (RN) professionally known for being an analytical thinker offering talent in continuous assessment and clinical oversight. A self-motivated team player displaying exemplary clinical skills promoting attention to detail with a drive to resolve issues quickly and efficiently. Remains poised in stressful environments with a proven record for keeping difficult situations calm and under control. Always puts the patient first and provides individuals with warmth, compassion, and dignity.

Experience May 2019 – Present South Austin Medical Center Austin, Texas Utilization Review, Registered Nurse, Observation-Case Manager

● Manage and streamline Observation work lists of up to 50 patients at a time by efficiently prioritizing and reviewing patients in observation longer than 24 hours.

● Perform initial, concurrent, and retrospective reviews utilizing evidence-based criteria (InterQual) and patient’s clinical through electronic medical records for appropriate bedding status.

● Collaborated cases with physicians when patients met or did not meet inpatient criteria and need for upgrading or downgrading status.

● Coordinate with the Interdisciplinary Team (IDT) requesting escalation for referrals, procedures, monitoring results, and evaluations to facilitate a successful care transition.

● Monitor OR CPT and Authorization Tracker for same-day surgery scheduling, appropriate bedding status per prior authorization, and MCR Part A inpatient-only list.

● Facilitate condition code 44 when MCR patients did not meet admission criteria for inpatient admission.

● Collaborated with attending physicians regarding CMS two-midnight rule for Medicare Part A patients in Observation status.

● Make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.

● Reviewed and analyzed treatments that patients received to ensure efficiency and cost-effectiveness.

● Maintain and exceed individual JCAHO compliance for Texas State Health Service HIPAA compliance and Medicare/Medicaid guidelines.

● Guide established production standards and operational objectives, case documentation, and telephone response requirements as established protocol

Experience January 2018 – January 2019 Piedmont HealthCare Atlanta, Georgia Utilization Review, Registered Nurse (100 % Remote)

● Conducted initial and concurrent reviews for all lines of business (Unfunded, Commercial, Managed Care, and Medicaid)

● Utilized evidence-based criteria (InterQual- MCR/MCG-) and patient's clinical electronic medical records for appropriate bedding status.

● Coordination with the interdisciplinary team escalating referrals, procedures, monitoring results, and evaluations to facilitate a successful care transition.

●Collaborated with physicians when patients met or did not meet inpatient criteria and needed upgrading or downgrading status.

● Monitored patients ensuring progression in their plan of care as well as meeting medical necessity for continued stay.

● Ensured that the patient's payer had clinical information to authorize the continued hospital stays, days, and services provided.

● Maintained effective communication with the interdisciplinary team Experience May 2015 – December 2017 Baylor Scott & White Health Temple, Texas Utilization Review, Registered Nurse (100 % Remote)

● Applied clinical acumen when focusing on prior authorization and concurrent review for all outpatient and inpatient clinically complex cases.

● Reviewed member and provider request for medical necessity criteria for coverage based on a review of the member's benefit certificate/document, applicable medical policies, procedures, evidence of coverage, a summary of plan details, and National and Local Coverage Determination.

● Drafted approval and denial letters based on case determinations. Forwarded cases that did not meet medical necessity criteria to the medical director for review. Completed administrative denials on services excluded by the member's benefit certificate/document and maintained compliance with events.

● Guided members and providers with the referral and authorization process, benefits interpretation, and other utilization issues. Called hospitals and case managers/utilization review departments to request clinical, inform the authorized days, and schedule peer-to-peer discussions between the medical director and attending physician.

Experience December 2014 – May 2015 St Catherine’s Nursing Home Albuquerque, New Mexico Resident assessment coordinator, Registered Nurse

● Coordinated, supervised, and evaluated the care of patients. Experience June 2011 – November 2014 Epic Health Services Houston, Texas Pediatric Registered Nurse

● Private duty Registered Nurse managing home patient care. Experience September 2004 – February 2011 Sol Amor Hospice Albuquerque, New Mexico Director of Clinical Services

● Responsible for the overall direction of Hospice Clinical Services. Education Trinidad State Jr College – Associates Degree in Nursing 1990 – 1992 Alamosa, CO Adams State University - Prerequisites for Nursing 1988 – 1990 Alamosa, CO San Luis Valley Vocational - Licensed Practical Nurse 1987 – 1988 Alamosa, CO Certifications Resident Assessment Coordinator - Certified Basic Life Support (BLS)

Ventilator & Tracheostomy

Private Duty Nursing

InterQual - Certified

Meditech Systems

Skills Utilization Review, Analysis, Health Insurance, Claims Processing & Compliance, Disease Management, Home Health, Hospice, Long Term Care, Acute Care, Skilled Nursing, Communication, Time Management, Appeals & Denials, Medicaid/Medicare Regulations,

(Software Expertise: Midas, Meditech, Epic, NaviHealth, MACE Medical, Office, Zoom, WebEx, Patients Portal, Electronic Medical Records(EMR), Electronic Health Records(EHR), OASIS) Lisa A. Hamilton – Cell: 512-***-**** – Email: adwp3a@r.postjobfree.com (Page 2 of 2)