Prior Authorization Case Management
Resume:
Linda A. Kleo, LPN
Anthem, AZ
adx8l9@r.postjobfree.com
PROFILE
Experienced LPN with 30 years of accomplishments in multiple capacities of nursing; management, hospital bedside medical surgical, physician practice, long term care, case management of worker’s compensation and utilization management processes
WORK HISTORY
2012 – Present Utilization Management Nurse 2, Medicare Sr. Products - Humana
Conduct inpatient concurrent review, prospective and retrospective, inclusive of Acute, SNF, LTAC, and Rehabilitation
Utilize interquels and CMS guidelines
Responsible for outpatient medical review and prior authorization for DME, Home Health Care, and Radiology
Review Provider Reconsiderations and Appeals
Implement Episodic Case Management
Participant of on call rotation for urgent requests
2009 – 2012 Arcadian Health Medicare Advantage Plan – UM Nurse
Inpatient concurrent review, prospective and retrospective, inclusive of Acute, SNF, LTAC, and Rehabilitation
Adept utilization of Interquel and CMS guidelines
Outpatient medical review and prior authorization for DME, Home Health Care, and Radiology
Provider Reconsiderations and Appeals
Episodic Case Management
On call rotation for urgent requests
2005 - 2009 New Jersey BCBS/Horizon NJ Health- UM Nurse
Prior authorization specialist in multiple areas within Health Services
Management of daily tasks inclusive of same day surgery, non-participating provider, and emergent prior authorization requests
Use of Milliman clinical criteria for determination
URAC and NCQA accountable
EDUCATION
LPN licensure in Arizona and New Jersey
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