Registered Nurse Utilization Management

Tracie Christie

*** ******** ****** **, *********, SC

SC License – RN# RN264794 and Expiration Date: 04/30/2026

Recruiter Summary:

Tracie is a Registered Nurse with an unrestricted license to practice in the state of South Carolina with 3+ years of experience with Appeals, Grievance, Denials, Claims, Utilization reviews, Case Management, discharge planning, Documentation review and working with various healthcare settings such as Humana.

Skilled in member access to services appropriate to their health needs or Performing utilization management involving concurrent review, prior auth, retro review, and discharge planning outpatient review.

Managing appeal for denied services and Knowledgeable in Utilization Review with all guidelines including, ACOEM, MTUS, ODG, Milliman, InterQual.

Assisting in the appeals and denial process by preparing correspondence, summarizing additional criteria, clinical documentation, and supporting information to facilitate the reversal of denials.

Work within a 24-hour turnaround time for acute admissions and appropriate window for appeals and denial determinations.

Proficient working with various EMR systems such as Epic and various providers for continuum of patient care and completion of medical reviews.

Consistently protect patient information in adherence to HIPAA guidelines while ensuring full compliance with Medicare/Medicaid (CMS) review policies and procedures.

Education:

University of Phoenix, Ontario, CA Apr 2006

Master of Business Administration in Healthcare Management

American International College, Springfield, MA May 1999

Bachelor of Science in Nursing

Skills:

Utilization management

Critical care experience

Discharge planning

Vital signs

Medical terminology

Managed care

Epic

Nursing

Critical care experience

Medical terminology

Workers' Compensation Law

Documentation review

Analysis skills

ICD-10

Nursing home experience

Professional Experience:

Humana - Louisville, KY Sep 2022 to Oct 2024

UM Appeal Nurse II

Ensure medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, behavioural health, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment settings by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers or programs of community resources.

Applies clinical knowledge to work with facilities and providers of care coordination. Works with medical directors in interpreting appropriateness of care.

Managing appeal for denied services.

Knowledgeable in Utilization Review with all guidelines including ACOEM, MTUS, ODG, Milliman, InterQual.

Consistently protect patient information in adherence to HIPAA guidelines while ensuring full compliance with Medicare/Medicaid (CMS) review policies and procedures.

Assisted in the appeals and denial process by preparing correspondence, summarizing additional criteria, clinical documentation, and supporting information to facilitate the reversal of denials.

Work within a 24-hour turnaround time for acute admissions and appropriate window for appeals and denial determinations.

Elevance Health – Remote Aug 2017 to Sep 2022

Nurse Case Mgr II/UM Nurse Med Mgt II

Ensures member access to services appropriate to their health needs.

Performed utilization management involving concurrent review, prior auth, retro review, and discharge planning outpatient review.

Conduct assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.

Implement care plan by facilitating authorizations/referrals as appropriate within benefits structure

or through extra-contractual arrangements.

Coordinates internal and external resources to meet identified needs.

Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

Interfaces with Medical Directors and Physician Advisors on the development of care management

treatment plans and inpatient hospital stay.

Core Medstaff - Los Angeles, CA Jan 2018 to Mar 2022

RN Acute care hospital/Skilled Nursing/Subacute/Home Health /Psych

Triaged and assessed patients by evaluating presentation, vital signs, and medical histories for proper

admissions, which resulted in faster service times and greater patient satisfaction

Modeled excellence with patient engagement, service delivery, and compliance with strict regulations,

resulting in the achievement of team performance goals and improved patient satisfaction

Corvel - Orange, CA Oct 2016 to Jan 2017

Nurse Case Manager Workers Comp

Provides medical case management to individuals through coordination with the patient, the physician,

other health care providers, the employer, and the referral source.

Assist in completing First Report of Injury/Illness form, investigate claim, as appropriate, and processes completed First Report forms per state regulations and customer guidelines.

Coordinate Independent Medical Evaluations.

Provide assessment, planning, implementation, and evaluation of patient's progress. Evaluate patient's treatment plan for appropriateness, medical necessity, and cost effectiveness.

Zurich Insurance - Schaumburg, IL Sep 2015 to Sep 2016

Nurse Case Manager Workers’ Comp

Performed Workers' Comp Telephonic Case Management. Remote home position.

Collaborated with providers and injured workers to devise effective treatment measures to expedite recovery process. Documented medical updates onto claim status reports submitted to and processed via claim adjusters daily.

Coordinated treatment and care measures required to support recovery process of injured workers.

Aetna - Hartford, CT Jul 2013 to Sep 2015

Registered Nurse Case Manager Workers’ Comp

Performed Workers' Comp Field Case Management. Flex-remote home position.

Travelled to local physician offices, visited with orthopaedics specialists/providers of injured workers to devise effective treatment measures to expedite recovery process.

Documented medical updates onto claim status reports submitted to and processed via claim adjusters daily.

Coordinated treatment and care measures required to support recovery process of injured workers.

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