Utilization Management Nurse - RN, DC License, Open to Relocate
Resume:
Jennifer Lynn Fenton
Utilization Management Nurse
******************@*****.*** • 419-***-****
LinkedIn • Dayton, OH, 45419
Accomplished and goal-focused professional with comprehensive experience in optimizing utilization review processes, streamlining claims adjudication, and improving care delivery standards within dynamic healthcare environments. Proven track record of leading comprehensive utilization review initiatives, managing high-volume case assessments, and coordinating interdisciplinary teams to enhance patient care. Adept at performing meticulous medical necessity evaluations, driving cost-effective solutions, and ensuring adherence to federal and state regulations. Skilled in streamlining prior authorization workflows, reducing claim denials, carrying out comprehensive chart audits, and fostering collaboration between clinical and administrative departments. Well-versed in training and mentoring staff, implementing educational programs, and advancing safety protocols. Known for delivering detailed analyses, supporting complex appeals, and leveraging expertise to achieve substantial cost savings and process improvements. Skilled in conducting comprehensive reviews of medical records, assessing treatment plans, and recommending appropriate levels of care. Excel at integrating evidence-based guidelines and clinical protocols into utilization review practices. Areas of Expertise
● Utilization Review Management
● Medical Necessity Review
● Case Management & Discharge Planning
● Worker’s Compensation Claims
Investigation
Professional Experience
● Patient Advocacy & Care
● Interdisciplinary Coordination
● Appeals & Denials Management
● Emergency Preparedness
● Prior Authorization Management
● Claims Adjudication & Processing
● Documentation & Record-Keeping
● Staff Education & Training
Medical City North Hills, North Richland Hills, TX RN Coordinator of Occupational and Employee Health 2024 — 2025
Create goals, objectives, marketing, and action plans in alignment with the department's mission and strategic initiatives. Deliver integrated services in adherence with occupational needs of the facility and the patients served by implementing systems and program plans. Ensure a safe working environment by investigating, evaluating, and addressing active exposures, injuries, near misses, and reports of hazardous conditions. Coordinate appropriate levels of care, including consultation, first aid, therapy, rehabilitation, and work restrictions as needed by serving as primary medical evaluator and case manager for all work-related illnesses and injuries. Manage and ensure timely processing of workers' compensation claims, providing administrative oversight. Remain current on changes and updates by maintaining compliance with legal and regulatory standards.
● Acted as liaison with legal counsel, government bodies, and regulatory agencies to ensure alignment and compliance.
● Promoted cohesive safety culture by collaborating with all departments and participating in health/safety-related committees.
● Managed operating expenses by optimizing supply and equipment utilization, identifying cost reduction opportunities, and implementing cost-saving measures.
● Enhanced health and safety awareness throughout the organization by conducting orientation for new employees and providing ongoing education.
● Directed emergency preparedness initiatives pertaining to occupational and employee health, including responses to emerging and reemerging diseases.
Southwestern Health Resources, Farmers Branch, TX
Prior Authorization Utilization Review Nurse
2022 — 2024
Assessed cases in accordance with the Code of Federal Regulation Title 42 SS414.234 (d) to ensure compliance and accuracy. Applied extensive knowledge of Medicare Advantage, commercial policy guidelines, and state regulations to manage prior authorization processes. Coordinated with multiple interdisciplinary teams, including denials and appeals to streamline case reviews and ensure cohesive decision-making. Performed comprehensive reviews for outpatient prior authorization services, covering wide range of medical services, such as radiation oncology, physical therapy, behavioral health, cardiac procedures, and diagnostic services.
● Utilized variety of criteria systems, including Milliman (MCG) and Interqual to conduct thorough evaluations.
● Ensured appropriate utilization and care standards by evaluating high-acuity inpatient and outpatient surgical cases. Buckeye Health Plan, Columbus, OH
Concurrent Review Nurse II/Utilization Review Nurse 2018 — 2022
Carried out comprehensive reviews for medical necessity in skilled nursing, acute inpatient rehabilitation, and long-term care facilities as well as acute long-term care hospitals, ensuring expedited payments to providers. Conducted meticulous chart audits for reconsideration of denied claims, retrospective review, concurrent review, and quality of care assessments, adhering to federal and state regulations. Maintained compliance and integrity by evaluating claims for potential fraud, waste, and abuse.
● Supported appeals process by providing detailed case analyses and documentation.
● Streamlined the approval process by developing and reviewing new prior authorizations
● Prioritized patient care and discharge planning while managing an average caseload of over 200 members.
● Enhanced team competency/efficiency by training/educating newly hired staff on all aspects of utilization review process.
● Co-led transitions of care team, achieving $3M in annual savings by collaborating with local social services organizations to leverage community resources and successfully reintegrate patients into the community. Health Care Support, Columbus, OH
Care Review Clinician II/ RN Utilization Review Nurse 2017 — 2018
Conducted detailed medical claim assessments for Molina Health Care and Centene Corporation, ensuring medical necessity and facilitating provider payments. Performed thorough chart audits and authored persuasive appeals for reconsideration of denied claims. Executed retrospective and concurrent reviews in compliance with federal and state regulations.
● Investigated Medicaid claims for fraud, waste, and abuse, ensuring accurate service documentation/claim adjustments.
● Played a key role in onboarding by training new temporary staff, imparting knowledge of review processes and guidelines.
Riverside Methodist Hospital, Columbus, OH
Behavioral Health Unit, Clinical RN, Charge Nurse
Level 2 Trauma Center, 42 psychiatric inpatient beds 2014 — 2017
Coached staff in use of EPIC computerized charting system and provided orientation to new hires on hospital policies and procedures. Performed thorough chart audits for denied inpatient psychiatric services, compiled documentation for appeals, and assisted in writing appeal requests for reconsideration. Led patient and family education groups on topics related to mental illness, recovery strategies, medication management, healthy boundaries, and lifestyle choices. Maintained safe environment for patients and staff by de-escalating potentially violent patients and visitors using nonviolent crisis intervention techniques and therapeutic communication.
● Co-chaired the evidence-based practice nursing and innovative research council, ensuring integration of research and clinical guidelines into practice.
● Ensured comprehensive patient care and service coordination by overseeing discharge planning, case management, concurrent reviews, and prior authorizations.
Additional Experience
Psychiatric Clinical Nurse, Sun Behavioral Health, Columbus, OH Behavioral Health Nurse Reviewer, Judge Technical Group, Columbus, OH Behavioral Health Unit, Clinical RN, Charge Nurse, Mercy St. Charles Hospital, Oregon, OH Medical Services /Manager/Nurse Educator, RN, Compass Corporation for Recovery Services, Toledo, OH Psychiatric Clinical, RN, Arrowhead Behavioral Health Hospital Maumee, OH Education
Bachelors of Science in Nursing, Lourdes College, Sylvania, OH Associates of Applied Science, Mercy College of Northwest Ohio Findlay, OH Awards
Nursing Excellence Award
Acknowledged for Leadership, Accountability, and Compassion Affiliations & Memberships
Chair of Employee Safety Committee
Co-chair of Evidence Based Practice Nursing and Innovative Research Council
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