Utilization Management & Quality Improvement RN Leader

Tiffany R. Ouellette, RN, BSN

**** ******* **. **********, ** 46112

*******@*****.*** 317-***-****

Indiana License # 28194966A

SUMMARY

Experienced RN and utilization management leader with expertise across Medicaid, Medicare, and Marketplace insurance. Skilled in leading daily operations, managing schedules and workloads, supporting compliance with state program guidelines, and collaborating with internal and external partners to promote timely, appropriate levels of care. Recognized for strong clinical judgment, team leadership, communication, and process coordination.

EXPERIENCE

Utilization Management Supervisor

Managed Health Services/Centene- Indianapolis, IN October 2019 – Current

Supervise daily utilization management operations, including staff scheduling, attendance, workload management, and departmental workflow.

Ensure compliance with applicable state program guidelines and support appropriate use of resources to facilitate the UM process.

Educate and coach staff to promote consistent performance, adherence to standards, and timely completion of work.

Assist the UM Manager and Director with coordinating system processes involving providers, partners, vendors, and subcontractors.

Quality Improvement Coordinator II

Managed Health Services- Indianapolis, IN February-2015 – October 2019

Reviewed delegated entities for compliance with quality, service performance, and medical record auditing standards to support care-gap closure.

Assisted with managing the 2017–2019 P4P/HEDIS project, including interviewing, hiring, training, and supervising temporary nursing staff.

Served as liaison between corporate staff and vendor teams, providing clinical subject matter expertise.

Reviewed and presented Quality-of-Care cases related to member concerns.

Nurse Consultant

Family Social Services Administration, State of Indiana- Indianapolis, IN March-2012 – February 2015

Reviewed medical records to determine Medicaid disability eligibility in accordance with Social Security Disability Administration guidelines.

Prepared and presented denial recommendations to the medical director.

Registered Nurse

St. Vincent Anderson Regional Hospital- Anderson, IN July-2011 – March 2012

Provided direct patient care in accordance with the Indiana State Nurse Practice Act.

Identified and prioritized patient health concerns based on assessments in respiratory and oncology units.

Home Care Nurse

Pediatric Nursing Specialists- Indianapolis, IN October 2011 – March 2012

Provided one-on-one PRN care for pediatric patients with complex medical needs, including tracheostomies, G-tubes, and portable ventilators.

Registered Nurse/Transitional Care

Kindred Healthcare-Greenfield, IN March 2011 – July 2011

Provided continuing care for patients recovering from illness or participating in rehabilitation services.

Supported complex care needs including IV therapy, wound care, enteral feedings, and rehabilitation services.

Adjuster Claims

Conseco Insurance (LTCG/Univita)- Carmel, IN July 2005 – March 2011

Processed long-term care claims by interpreting medical records and regulatory materials in accordance with state and federal guidelines.

Trained fellow employees in claims processes and documentation expectations.

EDUCATION

RN to BSN

Western Governors University, Millcreek UT

Graduated 2023

Associate of Science in Nursing

Med Tech College Indianapolis, Indiana

Dean’s list 2008-2010, GPA-3.8

SKILLS

Effective Leadership

Parent/Patient/Family Education

Time management

Ability to work independently or as a team.

Proficient with various software applications (Epic, Trucare, Availity, Xsolis, CWS, Microstrategy, Power Bi Reporting, FileNet, Faxcom, Microsoft 365 suite, Adobe Acrobat, Viva Insights)

Chart auditing

Planning and research

Communication

Conflict resolution

Familiar with both MCG & InterQual Guidelines

Contact this candidate