Healthcare Utilization & Case Management Specialist

PATRICIA A. WYATT

Roanoke VA

******@*****.*** / 813-***-****

SUMMARY

Licensed Practical Nurse with 20+ years of experience in utilization review, telephonic case management, Medicaid LTSS, and home health. Skilled in InterQual/MCG criteria, EMR documentation, remote assessments, and coordinating care across managed care and home health environments. Proven ability to manage high-volume caseloads, ensure medical necessity compliance, and deliver accurate, patient-centered clinical documentation. Seeking remote roles in Utilization Review or Telephonic Case Management.

SKILLS

Attention to Detail

Critical thinking and clinical judgment

Communication and active listening

Time management and prioritization

Problem-Solving & Decision-Making

Patient-centered care and empathy

InterQual and MCG clinical criteria

Appeals and denials case review

EMR systems (Epic, CarePort, etc.)

Medicaid LTSS and CCSP assessments

Clinical documentation and chart review

Utilization review and prior authorization

EXPERIENCE

Home Health Nurse / CenterWell Home Health - Roanoke, VA 08/2023 - Current Deliver skilled nursing care, chronic disease management, wound care, and patient education. Document all clinical care in EMR systems with accuracy and compliance. Collaborate with interdisciplinary teams to update care plans and coordinate follow-up. Identify early deterioration and support readmission prevention. Home Health Nurse (Part-Time) / Pruitt Home Health 01/2023 - 08/2023 Performed in-home visits, wound care, catheter care, injections, and lab collection. Completed timely assessments and updated documentation. Coordinated care plans with physicians and case managers. Telephonic Case Manager / Personify Health 09/2021 - 01/2023 Conducted telephonic assessments and developed patient care plans. Managed high-volume caseload ensuring timely follow-ups. Applied InterQual/MCG for medical necessity determinations. Appeals & Denials Nurse (Temp) / Health Support Staffing 01/2022 - 12/2022 Reviewed appeals and denial cases, ensuring accurate application of clinical criteria. Prepared documentation supporting medical necessity for reconsideration. Collaborated with physicians and UR teams to resolve case discrepancies. LPN Pre-Authorization / WellCare Health Plans 11/2013 - 12/2021 Conducted pre-authorization reviews for surgeries, DME, home health, and radiology. PA

Applied InterQual/MCG criteria and documented clinical rationales. Collaborated with providers to obtain missing clinical information. Travel Nurse, Case Management / MK Staffing 12/2020 - 02/2021 Supported case management workflows and coordinated patient needs. Entered and verified orders and managed incoming calls. Ensured documentation accuracy across care teams.

LPN Care Coordinator / Care Lync of Georgia 04/2019 - 09/2020 Completed Medicaid CCSP assessments and developed care plans. Coordinated referrals and follow-up services.

Maintained accurate LTSS documentation.

LPN Utilization Review (Contract) / Actalent Health Services 07/2018 - 04/2019 Performed utilization reviews for long-term care using InterQual criteria. Analyzed EMR documentation and escalated borderline cases. Ensured compliance with payer guidelines.

Case Manager / Anthem 10/2015 - 04/2018

Managed ~80-member caseload across home and assisted living settings. Conducted LTSS/CCC assessments and coordinated services. Reviewed medical necessity for ongoing care plans. EDUCATION AND LICENSES

Licensed Practical Nurse, Fairfax County School of Practical Nursing Florida Compact License, Eligible to practice in all compact states including Virginia

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