Utilization Review Prior Authorization

LELA BEAM RN

PROFILE

I have over ** years of clinical nursing experience and nearly a decade of

remote work in medical management in the areas of Utilization Review & Utilization Management, and Prior Authorization. I bring a unique combination of clinical depth, technical proficiency, accuracy and strong communication skills. I have broad experience with both private payor and Medicaid plans across multiple states.

EXPERIENCE

Registered Nurse, Leander ISD;Public Health, School RN — August 2022- Present & 2011-2016

Support pediatric patients with acute and chronic conditions including diabetes, asthma, anaphylaxis, and seizures.

Manage daily med administration, emergency triage, and care coordination. Lead communication with families, providers, and educational staff during 504/ARD planning and health plan development.

Utilize EMR, data tracking, and compliance monitoring systems in a fast- paced environment.

Utilization Review & Utilization Management RN; Evolent Health, Remote — August 2016-August 2022

Delivered telephonic clinical reviews and documentation for inpatient, trauma, transplant, pediatric, and home health services. Private payor health plan and Medicaid plans to include Texas, Arkansas, Illinois and Massachusetts.

Liaised with providers and facilities during real-time chart reviews using InterQual criteria.

Acted as transplant nurse liaison for Beacon Northern Lights Health Plan; participated in weekly MD rounds.

Managed complex UM cases across major hospitals including Massachusetts General and Arkansas Children’s, Dana Farber Cancer Institute. Worked across multiple platforms with high call volume, rapid documentation, and fast clinical decisions.

979-***-*****

********@*****.***

Greater Austin Area

Texas

LIC # 809395

Prior Authorization Nurse, LVN; Texas Medicaid & Healthcare Partnership – Remote/Hybrid, — 2006–2008 & 2009-2011

Managed prior authorizations for ambulance, air, and fixed-wing transport services for multiple Texas Medicaid plans.

Conducted real-time hospital and ER calls with rapid clinical assessment and documentation.

High call volume, fast-paced coordination with healthcare teams and transport services.

Earlier Experience Includes: — 2000-2006

Brackenridge Hospital – Mother-Baby/Postpartum/Nursery, acute care Texas A&M University Student Health – Staff Nurse, acute care Elite Nursing Services – Acute Care Relief Nurse

Bryan ISD & College Station Med Center – Med-Surg & Public School Nursing EDUCATION

Excelsior University; Albany, New York

Blinn College, Bryan, Texas LVN/RN Bridge Program 2005 Blinn College, Bryan, Texas — LVN, 2000

CORE COMPETENCIES

Remote Telephonic Triage & Patient Communication

Utilization Review (UR) & InterQual / MCG Proficiency ICD-9 / ICD-10 Coding Knowledge

Private & Public Health Plan Experience

Live EMR/Data Interpretation & Documentation

Call Center/High-Volume Phone Support

Pediatric & Chronic Care Management

Technical Adaptability Multi-System Navigation

Emergency Protocols & Escalation

Exceptional Clinical Communication

TECHNICAL PROFICIENCIES

InterQual

Microsoft Office Suite

EMR/EHR Systems (multiple)

Secure messaging platforms

Multi-line phone systems & call center software

Professional and Personal References available upon request

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