PHILIP LA ROSE

Gilbert AZ ***** 480-***-**** adynqk@r.postjobfree.com

Clinical Nurse Reviewer

Accomplished LPN, LVN, offers over ten years of experience in providing clinical and medical review procedures. Possess solid aptitude in clinical care, utilization management, denials/ appeals process and medical billing and the authorization process of medical services.

Medicare Guidelines & Regulations Medical Records Chart Review Coding Denial/Reconsideration Appeal Procedure Rights Managed Care Resource Data Reports Online Medical Reference Engine, Milliman Care Guidelines/InterQual Care Criteria.

PROFESSIONAL EXPERIENCE

Medical Reviewer – LPN / Prairie Quest Consulting-Luke Air Force Base, Phoenix AZ 2021- Present.

Managing Military Health System Referrals for Clinical Care.

Reviewing referrals for administrative, clinical completeness & appropriateness.

Co-ordinating with specialty Clinic (Internal & external) to obtain pertinent instructions and tests required prior to appointments.

Locating referral requests and ensuring appropriate documents are available prior to all specialty appointments.

Dispositioning all referrals placed by Facility providers to Medical Treatment Facility Specialty Clinics on base and off base to the contracted Medical Authorization Entity for approval.

Facilitating referral activities by participating in multidisciplinary team activities.

. Achievement: Efficient processing of 95-100 % of all referrals placed per work day to specific specialty clinic or to contacted medical authorization Entity for approval.

Clinical Reviewer-LPN Utilization Review TriWest HealthCare Alliance, Phoenix AZ 2019-2020.

Application of Clinical knowledge to make determinations for pre-authorization of specific procedures and services to ensure adherence to contract benefits.

Compiling of information needed to to process prior authorization requests and documentation in medical management information systems.

Preparation and presentation of more complex cases to Case management and Disease management as appropriate.

Communicated directly with the Veteran Administration Medical Department Center Nursing staff on clarification

of members approved care of services rendered under specific programs of the Veteran’s Administration.

Disease Management project-Veterans Administration patients with Diabetes needing Ophthalmology Care.

. Achievement: Assisted greatly as a care team member in the continuation of the rollout of the authorizations process under the Patient Centered Community Care program

Medical Review Nurse-Claims Conifer Health Solutions Phoenix AZ 2016-2018

Provided medical review of retrospective claims submitted for re-imbursement.

Provided Complete medical review for UB and HCFA claims as identified by the health plan.

Supported claim department personnel in providing clarification of medical terminology and practical application of code review edits.

Documented review results in a manner supportive of cost recovery and Medicaid & Medicare audit requirements.

Provided policy recommendations and developments related to adjudication of claims, claims medical review and other areas as required.

●Achievement. Reduction in percentage of the different categories of claims by 95% to attainable levels for calendar year 2017.

●Achievement. Assisted Project Performance Improvement Committee in meeting their established goals by providing reporting reviews and cost savings methodologies.

Case Manager/Utilization Review Nurse Chandler Regional Medical Center-Dignity Health Chandler AZ 2008-2016

Facilitated utilization review of admissions, concurrent and retrospective stay of patients according to service lines and /or payor group.

Obtained Certification for patient stay from the respective payor sources of the hospital and documentation of those as per their level of care assigned by the payor and determining appropriate status and level of care by applying InterQual criteria.

Delivered care management of patients admitted to the care units and assisted with discharge planning Carried a daily case of 28-30 patients on the Medical/Surgical/telemetry Unit for daily care management.

Communicated with the Attending Physician, Heath Plans Utilization review nurse and other members of the interdisciplinary team on discharge plans.

Identified and reported daily quality issues according to hospital protocols.

●Achievement. Steady and persistent reduction in the geometric mean of patient length of stay in the hospital.

●Achievement. Assisted In the overall productivity and efficiency of the Utilization Department.

EDUCATION LICENCES

Certificate in Practical Nursing, Mid-Manhattan School of Nursing, Board of Education, New York City

Applied Science Courses and Nursing Courses, University of State of New York, Albany New York

Arizona State Board of Nursing, Licensed Practical Nurse

California Board of Vocational Nursing & Psychiatric Technicians, Licensed Vocational Nurse

TECHNICAL SKILLS

Basic Computer Skills, Microsoft Word, Excel Spreadsheets, Cerner Application system, Midas, EZ cap, Macess Care Radius, End Coder Processing Optum 360 UHC. .

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