Utilization Review Case Management

PATRICIA WYATT, LPN

Powder Springs, GA 813-***-**** ******@*****.***

Accomplished Licensed Practical Nurse brings 20 years of experience encompassing managed care, utilization review, and re-authorization. Adept at all aspects of the utilization review process, reducing length of stay and providing patient education to improve overall wellness. Demonstrates excellent time management, organization, and analytical problem solving to facilitate in-home care and clinical expertise. Skilled at telephonically reviewing inpatient hospital medical and behavioral health admissions and assisting with coordination of discharge planning. Maintains up-to-date knowledge of state and federal regulations governing healthcare.

CORE STRENGTHS

Patient Management Utilization Review Case Management Grievances/Appeals Customer Service Documentation Review I Prior Authorizations Occupational Health Medical Records Auditing EMR Interqual Millman SalesForce Home Care Home Base Excel Microsoft/Workers Compensation

PROFESSIONAL EXPERIENCE

MK STAFFING-Travel Nurse 12/2023-2/2024

Performed case management in a primary care unit. Place labs in computer, print lab orders, send medication refills to physicians. Answer the phone route calls. Assist physician as needed.

LPN CARE COORDINATOR Care Lync of Georgia. 4/2023-9/2023

Performed in-home assessments for a Medicaid-based CCSP waiver source.

Contacted clients to encourage follow-through with assessments; completed approximately three assessments daily.

Implemented a care plan with the client and designated power of attorney with focus on achieving health goals.

LPN UTILIZATION REVIEW TEMP CONTRACT Actalent Health Services –7/2022-4/2023

Provided clinical review/utilization review service of long-term facilities and admissions, pre-authorization using Interqual.

Investigated EMR for clinical determination, requested additional information and elevated to medical director for unsure determination.

LPN TRAVEL -PHYSICIAN OFFICE - CONTRACT Maxim Healthcare Group 11/2021-02/2022

Floated to several specialty physician offices, conducting patient assessments and prioritizing data to treat urgent needs.

Performed front desk functions, including checking in patients

Assisted physician, administered vaccines

Documented labs and vital signs in the patient's chart using EMR system.

Educated patients on their disease process.

LPN TRAVEL HOME HEALTH/Core Medical Staffing 8/2021-11/2021

Scheduled appointments and traveled to clients’ homes to perform wound care, labs, comet catheter placement, and personal care for approximately seven patients daily.

Instructed patients on their disease process and encouraged personal engagement in their health goals.

Collaborated with healthcare team to develop individualized care plans.

CASE MANAGER Anthem-10/2017-04/2021

Held several short and long-term roles at Anthem over a four-year period.

Facilitated the Long-Term Services and Supports (LTSS CCC) program, providing assessments and individualized care plans.

Managed a caseload of ~80 patients over ~12 assisted living facilities and in their homes.

Brokered in-home care resources for patients, arranged meal deliveries, oversaw DME needs, and called members monthly for updates.

Reviewed EMR records to determine medical necessity for procedures, hospitalizations.

LPN-CONTRACT- 08/2019-01/2020

Processed clinical appeals and grievances and reviewed for medical necessity employing Interqual.

Requested medical information, reviewed EHR to support members’ appeals, and prepared denial letters.

Sent to second level if criteria were not met.

UTILIZATION-REVIEW Keystone-11/2015-10/2017

Delivered review of EMR records and insurance to verify requirements for inpatient stays at various hospitals; completed task on time and in compliance with Medicaid regulations.

Review medical records using Interqual

TELEPHONIC/PREAUTHORIZATION-

WellCare Health Plans 11/2013 –04/2015

Assigned and reviewed the medical records for medical necessity using Interqual and MCG guidelines

Sent data to physician for a second level review.

Called and maintained good relationships with the hospital case managers.

Collaborated with various agencies to provide information on community resources

Pre-authorization for surgeries, DME, home health, IV infusion. Radiology tests to include MRI and pain management.

EDUCATION CREDENTIALS

Licensed Practical Nurse, Fairfax County School of Practical Nursing

LPN States of Florida, Virginia, Texas, and California

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