-Highly organized, focused, R.N. with 18+ years of utilization review / utilization management and complex discharge planning.
-Self motivated, successful work-at home/remote worker, since 2005, with proven ability to perform with minimal supervision.
-Skilled at multi-tasking, prioritizing clinical and operational tasks and analyzing/ collecting medical data and/or information.
-Favorably coordinates patient care with multidisciplinary teams and payer sources to promote quality outcomes.
-Reliable healthcare knowledge, including managed care operations within corporate, as well as, inpatient setting.
-Possesses clear verbal and written communication skills and sound technical abilities in standard office software.
Responsible for the review and resolution of clinical documentation, clinical appeals and complaints. Reviewing and analyzing medical information and interpreting the data obtained from clinical records. Data gathering requires navigation through multiple system applications. Condense complex information into a clear and precise clinical picture. Apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for both member and provider issues.
Utilized clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to assist and or facilitate appropriate healthcare services and benefits for members.
Gathered clinical information and applied the appropriate clinical criteria /guidelines, policy, procedure and clinical judgment to render coverage determination/recommendations along the continuum of care.
Ensured medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers, programs or community resources.
Determined appropriate levels of coverage for inpatient stay using clinical judgment and application of Milliman Care Guidelines to meet the members needs.
Performed admission reviews and authorizations based on medical necessity; obtained continued stay authorization for cardiac and orthopedic procedures/inpatient admissions.
Coordinated individualized discharge plans to manage safe transition back into community and home environment for a 50 bed orthopedic unit by organizing clinical documentation, treatment plans and referrals.
Provided direct patient care, stabilized patients and determined next course of action. Performed frequent check on medical equipment and made necessary adjustments to preserve optimal patient conditions. Delivered medications via oral, IV, intramuscular injections and monitored responses to catch and address new concerns. Followed and complied with HIPPA laws and all health data procedure to prevent information breaches.
Was team-lead for several years while working as UM nurse consultant.
Participated as the "back up" preceptor / trainer / educator for other preceptors on the team when necessary, for example another nurse requiring PTO.
In 2012, initiated and piloted FLEX scheduling with another team member and was very successful in this role
Consistently meet, and usually exceed, all required metrics.
Complete and successfully pass all required learning center and educational courses in a timely manner
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