Case Manager Utilization Review
Resume:
Leslie Gibson, RN, BSN
Registered Nurse Utilization Review &
Case Manager
** ***** ** ********** ** various hospital settings including CM, Cath Lab, ICU, ER, Radiology. 2 years in Utilization Review and 6 years Case Management. Full Time RN Utilization Review and Outpatient Case Manager 11/6/2023 - 3/26/2025 Crescent Health Solutions - TPA, 828-***-****
● Remote work setting - Home office
Conducts medical necessity reviews for a health insurance TPA using Milliman guideline. Daily reviews include: level of care for admissions, continued stay reviews, outpatient imaging, procedures and DME. Identify next-level review criteria. Generation of determination letters and coordination of appeals. Member benefit verification and enrollment status. Screening for Case Management appropriate members. Quarterly phone calls for CM members to provide guidance and coordination of care.
Highlights of Contributions: Process improvement and implementation lead for the Health Management team. Optimizing review criteria to enhance time efficiency while maintaining cost-saving protocols. Identifying and updating outdated processes in collaboration with leadership and CMO. Serve as an educator for new computer software training and data transfer. Development of educational tools, including software step-by-step guides for team members, member benefit charts, and quick-reference materials for non-clinical call center employees. Part Time RN Case Manager 04/17/2023 to 11/03/2023 UNC Pardee Hospital, 828-***-****
● ICU,PCU,Ortho, Medical Surgical, Womens and Children Responsible for discharge planning and coordination of care through collaboration with the provider, interdisciplinary team, patients and families with ability to critically troubleshoot healthcare barriers for best patient outcomes. Daily optimization of clinical outcomes and patient satisfaction while managing the cost of care and promoting efficient utilization of resources. Guidance of healthcare benefits including Medicare, Medicaid, commercial insurance and veteran service connection. Arrange DME and outpatient services such as hospice, home health, private duty nursing, outpatient therapies, etc. ALF and SNF placement for STR and long term residency. Coordination for acute hospital, LTACH, IPR, and GIP transfers. Screening/referrals for community based programs for uninsured and underprivileged populations. Coordination for substance abuse admission into rehab programs and outpatient support. Troubleshooting any barriers to discharge or high risk readmissions to ensure a successful and safe discharge.
RN Inpatient Case Manager 8/27/21 to 02/11/2023
AMN Healthcare, Revenue Cycle Solutions, 813-***-****
● Riverside Medical Center: Trauma-Surgical ICU (13 week contract) 8/27/21-12/25/2021
● Advent Medical Center, Hendersonville: M/S, PCU, ICU (13 week contract) 1/17/2022-5/30/2022 & ( Hospital employed PRN CM) 11/21/2022 - 1/31/2025
● Haywood Regional Medical Center:(UR - InterQual ) ICU, PCU, M/S (26 week contract) 7/25/2022-2/26/2023 ********@*****.***
Full Work History Available Upon Request
1
RN Inpatient Case Manager 7/1/2019-6/4/2021 (remote from 11/2020 - 6/2021) Vidant Medical Center, 252-***-****
Medical intermediate unit /COVID 19 unit
Same as above with inclusion COVID specific care beginning March 2020. Sole Case Manager for managing the inpatient population of only COVID 19 + patients on the COVID unit. Responsible for discharge planning with the ability to critically think for best outcomes for this special population of patients in a setting that is rapidly changing. Population: Medically complex on intermediate unit, initial COVID 19 positive patients . RN Cath Lab, EP 02/2018 –5/17/2019
UT Southwestern Medical Center, 214-***-****
● Cath Lab and EP Circulator, Recorder
Administering moderate sedation, circulator for cath lab procedures including coronary angiogram with high risk PCI’s, CTO’s, valve studies, right heart cath with leave in swan placement, endomyocardial biopsies, PFO/ASD closure, mitral clips, valvuloplasty. Ablations for Afib (RF or Cryo), SVT, VT and implantable devices: pacemakers, defibrillators, Watchmen, loop recorders.
RN Cath Lab 11/2016-12/2017
Baylor Heart and Vascular Hospital, 214-***-****, 877-***-****
● Cath Lab Circulator
Same as above cath lab experience with the following additions. Vascular studies, fistulogram, angiogram/venogram of extremities and carotid arteries, lysis catheter placement with thrombectomy via Angiojet. RN Noninvasive Cardiology, Minimally Invasive Interventional Radiology 6/2014-11/2016 Walnut Hill Medical Center, 972-***-****
● Noninvasive Cardiology, Radiology
Screen all patients for procedures such as TEEs, Cardioversions, Stress Tests, Defibrillator function test. Coordination for device reps, anesthesia. Lead RN duties: RN schedules and PTO approval, initiation of new policy and practices for a startup facility:
General Highlights: Member of the Peer Review Committee; Patient Safety Committee. Implementation of new hire orientation and skills check off. Creation of RN Bedside Swallow Eval, Emergent Contrast Reaction Protocol, MD order sets for Noninvasive Cardiology, patient flow process for Same Day Surgery, Stress test Rx protocol (with pharmacy coordination).
RN ER, 12/2011 – 3/2014; RN MRI, 9/2013 – 11/2014
Texas Health Resources, Presbyterian Dallas, 214-***-**** Travel ICU and ER RN, 11/2005 - 12/2011
Various Travel agencies -see full work hx
********@*****.***
Full Work History Available Upon Request
2
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