Experienced utilization review RN
Resume:
KIM MINGER
*** * **** ****** ******** Springs, FL 32435
*************@***.***
WWW: Bold Profile
PROFESSIONAL SUMMARY
Experienced Utilization Management Specialist with extensive background in healthcare and insurance sectors. Proven expertise in executing utilization review processes, analyzing medical policies, and collaborating with healthcare providers to enhance patient care. Key strengths encompass exceptional analytical capabilities, thorough knowledge of regulatory compliance, and proficiency in devising effective cost management strategies.
SKILLS
InterQual, MCG, and electronic health records
Microsoft Office proficiency
Utilization management and clinical assessments
Expertise in Medicare and Medicaid reviews
Team engagement and culture
Cross-functional collaboration
WORK EXPERIENCE
CLEARLINK PARTNERS
Saint Paul, MN
Utilization Management Specialist RN 07/2025 to Current
Reviewed and analyzed inpatient medical records for compliance with utilization guidelines.
Collaborated with healthcare providers to facilitate patient care and resource allocation.
Documented utilization review findings in the electronic health record system.
Implemented process improvements to streamline utilization management workflows.
Monitored compliance with regulatory requirements related to utilization management activities.
Participated in interdisciplinary meetings to discuss patient care plans and review medical records.
CENTENE CORPORATION/HEALTHNET
New Jersey
Utilization Review Specialist 01/2025 to 07/2025
Worked with MCO companies and patients to determine best courses of action.
Interpreted coverage policies and benefit provisions as they relate to the clinical setting.
Reviewed medical records to determine the necessity of services.
Collaborated with healthcare providers to clarify treatment plans.
Documented utilization review findings in electronic health records.
Communicated review decisions to providers and patients effectively.
CLOVER HEALTH SERVICES
Remote
Utilization Review Nurse 10/2024 to 01/2025
Conducted comprehensive reviews of medical records for authorization compliance.
Collaborated with healthcare providers to clarify patient treatment plans.
Monitored ongoing cases to ensure continued adherence to treatment protocols.
Participated in quality improvement initiatives to enhance review accuracy and efficiency.
Trained new staff on utilization review processes and best practices.
MEDIX STAFFING SOLUTIONS
Remote
Case Reviewer III/UR - Behavioral Health 04/2024 to 09/2024
UM duties as above
CLOVER HEALTH SERVICES
Remote
Telephonic Case Manager/Utilization Review Nurse 10/2023 to 03/2024
Conducted post-service inpatient medical claim reviews utilizing ClaimLogiQ (CLQ) for accurate billing assessment.
Conducted telephonic case management, providing comprehensive patient assessments and coordinating care plans.
Evaluated medical records to ensure compliance with appropriate hospital stay billing practices.
Assessed trauma service billing against county and ACS guidelines for accuracy and regulatory compliance.
Analyzed clinical documentation to support or refute medical necessity claims.
CIGNA
Nashville, TN
Senior Analyst / Telephonic Case Manager - Behavioral Health 02/2023 to 09/2023
Conduct comprehensive case management tasks, including inpatient and outpatient reviews, admission and discharge planning, and retrospective analyses.
Execute data collection and abstraction of Protected Health Information (PHI) for quality measures and audits, such as HEDIS and CMS, ensuring accuracy and compliance.
Executed retrospective and prepayment audits on claims for Government and Commercial Payers to ensure accuracy and compliance with billing practices.
LUCENT HEALTH
Nashville, TN
RN Clinician/Telephonic Case Manager - Behavioral Health Case Manager 09/2022 to 02/2023
Conduct comprehensive case management tasks, including inpatient and outpatient reviews, admission and discharge planning, and retrospective analyses, adhering to Lucent Home Health protocols.
Manage telephonic case management for behavioral health, including care coordination, assessments, and patient follow-up, adhering to Lucent Home Health guidelines.
Handle case management and claims evaluations for Medicare and Medicaid patients, ensuring compliance with federal regulations and program requirements.
Execute data collection and abstraction of Protected Health Information (PHI) for quality measures and audits, such as HEDIS and CMS, ensuring accuracy and compliance.
Assess and validate claims for appropriateness of services rendered in both inpatient and outpatient environments, performing necessary audits.
Execute retrospective and prepayment audits on claims for Government and Commercial Payers to ensure accuracy and compliance with billing practices.
Administer patient care procedures, including vital signs monitoring, and provide medication therapy and physician support services under clinical supervision, addressing and resolving care barriers to meet patient outcome goals.
EDUCATION
MASTER OF SCIENCE: NURSING LEADERSHIP/EDUCATION 03/2015
Wilmington University, New Castle, DE
BACHELOR OF SCIENCE: NURSING 01/2013
Wilmington University, New Castle, DE
ASSOCIATE OF APPLIED SCIENCE: NURSING 12/2000
Gulf Coast State College, Panama City, FL
CERTIFICATIONS AND LICENSES
• BLS Certification, 04/01/25, 04/01/27
• Compact State Nurse License, 01/01/23, 01/01/27, Tennessee
• CA RN License, 01/01/23, 01/01/27
LANGUAGES
English, Fluent
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