Utilization Review Medical Records

PATRECE L. JEFFERSON, LPN

**** ******* ***** **** *****, AR 71603 870-***-**** **********.***@*****.*** Licensed Practical Nurse

Profile:

Summary: Attentive, patient-focused, and devoted Licensed Vocational Nurse with a demonstrated background of nursing experiences with excellent communication skills, attention to detail and I have recently obtained Utilization review experience with remote learning services course in Utilization Review-101 and have been at my current utilization position for 2 years. I have recently completed contract work for HEDIS abstraction I pride myself on having a solid knowledge base, high-level critical thinking skills and ability to apply evidence-based guidelines that is needed in nursing. My clinical background in Chronic Care nursing has given me the foundation that's needed in Utilization Review.

Areas of Expertise:

● Telephone Remote Nursing

● Critical Thinking

● Medication Reconciliation

● Review Medical Records

● Claims Research Knowledge

● Clinical Administration

● Problems Solving

● Adaptability

● Teamwork

● Time Management Skills

● Excellent Communication Skills

● Customer Service

● Prior Authorizations

● Care Management

● Disease Management Skills

● Utilization Management

● Telephone Triage Nursing

● HEDIS Gaps

Certifications and Licenses

● LPN licensure in Arkansas (Compact), Illinois, and Massachusetts Professional Experience

Utilization nurse review, Health help WNS, Jan 2022-Current

• Assure access to appropriate levels of care.

• Responsible for conducting medical necessity reviews:

• Provide high quality, cost-effective services for all Members.

• Provide for Member and Provider satisfaction.

• Maintain time management and daily production.

HEDIS abstraction Nurse — Feb 2021- Feb 2022

Optum, United Health (Contract)

HEDIS experience: 1 season of abstraction with Optum and MEDIS 101 class with Marie Peppers which was equivalent to year.

• Assess medical records and clinical information to perform an analysis of a facility quality of care.

• Assess the data to identity information that proves that the facility met those requirements

• knowledge of HEDIS measures to pull adequate information to prove compliance

• Review provider treatment records against clinical and procedural established standards

• Conduct ongoing activities which monitor established quality of care standards in the participating provider network and for care managers Telehealth Nurse, Accent-care Apr 2019 – Jan 2022

• Advance patient care by analyzing high-risk populations and collaborating cohesively with cross-functional healthcare providers to ensure all needs are met.

• Contribute ongoing value to patients by regularly assessing case updates and determining if any additional needs are necessary.

• Demonstrate expertise in proper triage, charting, and examinations upon patient intake.

• Ensures all services provided to Commercial, Medicare and Medicaid managed care members are following program regulations, insurance regulations, and regulatory requirements.

• Conducts 20-25 telephonic, face-to-face visits via video

• Act as liaison to Hospitals and the medical community, providing education regarding the appropriate applications and opportunities provided by telemedicine.

• Display a solid understanding of state, federal, HIPAA, and CDC guidelines

• .Completes clinical assessments of patients.

• Performs ongoing monitoring of the care plan to evaluate

• effectiveness, document interventions and goal achievement. Education

LPN Program Diploma, SOUTHEAST ARKANSAS COLLEGE, Pine Bluff, AR. Associate Degree in General Studies, SOUTHEAST ARKANSAS COLLEGE, Pine Bluff, AR.

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