Utilization Management Nurse Lead Resume Example Innovista Health Solutions

UTILIZATION MANAGEMENT NURSE LEAD

Summary

I am creative and enthusiastic with progressive management skills and diverse capability range in many areas of nursing services. I have proven ability to work with physicians and other healthcare professionals to achieve quality, safety and financial and patient satisfaction.

Skills

Mastery of Microsoft, Word, Office Outlook, Excel, and Power point.
Proficient with McKesson, Epic, Cernel
Professional written communication abilities
CPR Phlebotomy Certified
Train the Trainer Certified (Instructor for CNA)
Reviewed and revised policies and procedures.
Lead fiscal management of telemetry and critical care operating budget for nursing and hem-dialysis.

Milliman (MCG) and InterQual Trained
Professional relationships
Knowledge of auditing systems
Professional communication
Director of Telemetry/Clinical Manager for ICU and Telemetry
Familiar with HFAP, Joint Commission, and NCQA Certification
Certification Fellow Community Health Center Executive Management

Experience

Innovista Health Solutions | Oak Brook, ILUtilization Management Nurse Lead09/2018 - 10/2019

Adheres to accreditation, contractual and regulatory time frames in performing all utilization management review processes.
Performed initial, concurrent and retrospective review activities, discharge care coordination for determining efficiency, effectiveness and quality of medical /surgical services and servicing as liaison between providers and Medical and Network Management Divisions with the three IPA groups assigned too.
Consulted with the Medical Director on all cases that do not meet clinical criteria
Advocated for patients by identifying insurance coverage, communicating care preferences to practitioners and verifying interventions met patients' treatment goals.
Utilized computerized Resource and Patient Management System Maintains accurate and timely documentation in the Electronic Health Records (EHR) and review cases using MCG (Milliman) and/or Interqual criteria.

Family Health Network | Chicago, ILCase Management & Transition Care Nurse01/2015 - 03/2018

Observed strict confidentiality and safeguarded all patient-related information.
Oversaw assigned utilization review activities and transitional care duties on a daily basis, ensuring level of care and length of stay was medically appropriate.
Reviewed, oversaw, and intervened with discharge planning needs, ensuring coordination and continuity of health care for enrollment's as they transferred between locations or different levels of care.
Followed up with patient family member post-discharge as part of their transition of care, aiding in member not being remitted.
Provided leadership support to clinical staff, professional and nonprofessional teams. Accountable for day-to-day operation for clinical staff of 19-bed telemetry unit and 15-bed intensive care unit on 24-hour coverage by phone or pager

Saint Anthony Hospital | Chicago, ILRegistered Nurse Clinical Manager03/2011 - 10/2014

Provided leadership support to clinical staff, professional and nonprofessional teams. Accountable for day-to-day operation for clinical staff of 19-bed telemetry unit and 15-bed intensive care unit on 24-hour coverage by phone or pager.
Successfully implemented quality improvement for core measures, decreasing agency cost due to vacancy in telemetry unit by hiring qualifying staff.
Resolved staffing issues by recruiting and hiring top-level talent.
Consulted with healthcare clients on nursing procedures and policies, implementing changes for improvement.

PCC Community Wellness Center | Oak Park, ILClinical Administrator05/2008 - 05/2011

Coordinated delivery of exceptional patient care by evaluating workflow and facilitating positive patient and physician changes for customer satisfaction.
Provided leadership support for clinical staff.
Provided administrative accountability to include assessment, planning, implementation, and evaluation of delivering quality patient care.
Participated in QA & PI process, clinic's strategic plan. Developed and implemented P&P. Coordinated daily operation to ensure quality patient care. Monitored budget in a cost-effective manner.
Resolved conflicts promptly among physicians, nurses and other healthcare employees to keep workflow on task.
Recruited well-qualified candidates to fill vacancies and offer residents unparalleled care.

Education and Training

Spertus Institute For Jewish Learning And Leadership | Chicago, ILMaster of Science in Human Services05/2005

Chicago State University | Chicago, ILBachelor of Science in Nursing Science12/2001

Malcolm X College | Chicago, ILAssociate of Science in Nursing Science05/1992

ADDITIONAL RELEVANT EXPERIENCE

ADVOCATE HEALTH CARE, CHICAGO, IL
Nursing Administrative, Patient Care Services/ Patient Care Coordinator/ Case Manager / Supplemental Staffing Agency

MOUNT SINAI HOSPITAL, CHICAGO, IL
Registered Staff Nurse, Staff nurse, Telemetry and ICU unit, and Utilization& Quality Management

NORWEGIAN AMERICAN HOSPITAL, CHICAGO, IL
Reviewed and revised policies and procedures. Implemented hospital wide quality including SBAR criteria for best practices in communication.

Resume Overview

Companies Worked For:

Innovista Health Solutions
Family Health Network
Saint Anthony Hospital
PCC Community Wellness Center

School Attended

Spertus Institute For Jewish Learning And Leadership
Chicago State University
Malcolm X College

Job Titles Held:

Utilization Management Nurse Lead
Case Management & Transition Care Nurse
Registered Nurse Clinical Manager
Clinical Administrator

Degrees

Master of Science in Human Services
Bachelor of Science in Nursing Science
Associate of Science in Nursing Science

Utilization Management Nurse Lead Resume Example

Resume Score: 80%

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