Case Manager Management

Stacy DeLo, RN, BSN

912-***-**** ️ *********@******.***

Professional Summary

Highly experienced Registered Nurse and Case Manager with 25 years in utilization review, appeals, care coordination, and managed care. Adept at analyzing clinical documentation, conducting concurrent and retrospective reviews, and ensuring compliance with Medicare/Medicaid guidelines. Proven ability to apply evidence-based criteria (InterQual, MCG) to determine medical necessity, streamline care transitions, and advocate for patient-centered care. Seeking a remote case management role to leverage expertise in utilization management, appeals, and preauthorization.

Key Skills & Competencies

Utilization Review (UR) & Appeals

Case Management & Care Coordination

Medical Necessity & Compliance (CMS, NCQA, URAC)

Concurrent & Retrospective Reviews

Medicare & Medicaid Regulations

MCG & InterQual Criteria Application

Preauthorization & Denials Management

EMR Systems & Clinical Documentation

Communication & Patient Advocacy

Professional Experience

Appeals Nurse Consultant Aetna (Remote) Nov 2021 – Sept 2023

•Conducted clinical appeals and grievance reviews for members and providers.

•Applied MCG/InterQual criteria and regulatory guidelines to determine medical necessity.

•Reviewed medical records to assess appropriateness of inpatient and outpatient care.

•Collaborated with physicians, case managers, and insurance providers to resolve appeals.

•Summarized complex medical data into concise, evidence-based determinations. Shift Administrator Wayne Memorial Hospital Sept 2023 – Mar 2024

•Oversaw hospital-wide operations, including staffing, patient flow, and resource allocation.

•Assisted in interdepartmental problem-solving and escalated issues to leadership.

•Ensured compliance with hospital policies, safety protocols, and budget constraints. Unit Manager Altamaha Healthcare Center Mar 2024 – Aug 2024

•Managed a team of LPNs and CNAs, ensuring high-quality patient care.

•Conducted care plan assessments, interdisciplinary team meetings, and compliance audits.

•Optimized workflows to enhance efficiency and patient outcomes. Hospice RN Case Manager (RNCM) GHC Hospice, GA Sept 2019 – 2021

•Coordinated care for chronically ill and end-of-life patients, ensuring quality and dignity in care.

•Managed prior authorizations, insurance verification, and care planning.

•Educated families on treatment plans, medication adherence, and symptom management. ED Charge Nurse Ft. Stewart, GA 2004 – 2019

•Led triage, admissions, and emergency interventions in a high-volume ED setting.

•Ensured rapid assessment, stabilization, and referral of patients.

•Managed EMR documentation, patient flow, and multidisciplinary communication.

Education & Certifications

Utilization Review-101, Remote Learning Services (2021) Bachelor of Science in Nursing (BSN), Augusta University (1999) Associate of Science in Biology, College of Coastal Georgia (1995)

Licensure & Certifications

Registered Nurse (RN), Georgia Board of Nursing – RN150162 (Exp. 01/31/2026) MCG & InterQual Criteria Training

HIPAA & CMS Regulatory Compliance Training

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