Fifteen years of clinical experience in primary care including Medical Surgical and Neonatal ICU. Over 11 years of experience in Utilization Review, Discharge Planning working directly with Interqual/ Milliman and DRGS. Familiarity with ICD and CPT coding. Experience with HEDIS reviews, Medicaid and Medicare. Worked remotely for the past 10 years and have excellent autonomous analytical and decision making skills.
RN license in the state of Delaware and Pennsylvania.
McKesson Certified in 2001.
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Perform daily utilization review and discharge planning for medicaid members in acute and sub acute settings. Present cases to the medical team including medical directors and case managers to coordinate timely and appropriate care. Developed a team approach regarding daily reviews which was adopted by the Utilization Management team.
Conduct utilization management review remotely on a daily basis applying Interqual criteria. Interact with medical directors, case managers and the behavior health to ensure successful outcomes for the patient. Developed new systems and policies to aid in streamlining work processes.
I worked temporary positions in the insurance industry conducting HEDIS reviews for Aetna and provided utilization management for Keystone Mercy and BCBSDE using Interqual and Milliman criteria for per diem and DRG facilities.
Provided for neonates in a clinical setting. During time at Christiana I also obtained a weekend Utilization Review position and became McKesson certified. The position enabled me to transition out of the clinical setting to the Utilization Management area.
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