Driven and compassionate healthcare professional with over 15 years of experience in utilization review, telephonic case management and the specialty pharmacy setting. A critical thinker with excellent time management skills and a can-do attitude. Seeking a position for a progressive provider with a commitment to innovative processes.
Personal and professional integrity
Claims analysis and review specialist
Familiarity with disease management programs
Staffing management ability
Certification in managed care nursing
Licensed in NY, FL, TN, TX, CA
ICD-10 coding experience
Conduent CareSolutionsLakeland, FLUtilization Review Nurse03/2005 to Current
Performed prospective, concurrent and retrospective utilization reviews per specified state and national guidelines. Developed and maintained effective professional relationships with clients, medical providers and business partners. Demonstrated excellence in communications to ensure customer satisfaction and retention to produce result-oriented service. Followed all standards, procedures and protocols to maintain URAC accreditation. Utilized nationally recognized evidence based guidelines to make medical-necessity decisions. Provided after hour utilization review of medications to determine authorization, relation to the injury and appropriateness.
In the triage nurse role, gathered medical information about the injured claimant for consideration of referral for medical case management services, identified pertinent medical history, prior injuries, pre existing conditions and the appropriateness of the treatment plan. Coordinated medical care for medical only claims and direction of care into the approved provider networks for cases not referred for case management services.
Sprectrum Healthcare ResourcesTampa, FLReferral Management Nurse- Civilian Contractor08/2004 to 03/2005Reviewed specialty care referrals for appropriateness and covered benefit, serving as a functional expert in area of health benefits. Provided medical consultation and administrative support for the medical treatment facility by assisting beneficiaries with specialty care referrals, ensuring members received information in a timely manner. Assisted with specialty care appointments and pre-appointment instruction to facilitate continuity of care. Facilitated communication between beneficiaries, medical treatment facility staff, network providers and ancillary healthcare providers.
Priority HealthcareLake Mary, FLNursing Supervisor02/1999 to 08/2004Provided disease specific education and clinical support to patients with chronic illnesses to ensure therapy efficacy, compliance and desired positive outcomes. Hepatitis C nurse specialist. PAH clinical trials staff. Performed prior authorization and utilization management. Participated in quality assurance improvement. Recognized for solid supervision, coaching, training skills and unparalleled customer service skills. Built a reputation for upholding high ethical standards to achieve corporate goals and objectives.
Professional Experience 1987-1999
Visiting Nurse Association Field Nurse
Provided case management of 25-30 patients with high risk, complex needs and catastrophic illnesses in a prospective payment program. Performed in-home assessments, participated in multidisciplinary team conferences, evaluated options, and services/resources, contributing ideas and problem solving effectively with other team members for efficient methods in the delivery of care, promoting quality outcomes, and cost effectiveness. "Shu the Flu" campaign staff. Active intake, referral and patient telecommunications.
Elkhart General Hospital-Float Nurse
Provided total patient care to in-patients including medication administration, IV therapy, post surgical wound care and telemetry monitoring. Rotated among various clinical services within the institution including ICU, CCU, PCU, Medical Surgical, Orthopedics, Pediatrics, Nursery and Post-Partum units. Participated in unit quality improvement initiatives.
Excelsior College, Albany, NYBachelor of Science in Healthcare Management, MBA Completion May 2019
1987Indiana Vocational Technical College, South Bend, INPractical Nursing
Nursing, Healthcare, Utilization Review, Managed Care, Healthcare Information Technology, Patient Education, Disease Treatment Management, Case Management, Healthcare Management, Specialty Pharmacy, Triage, Home Care, Medicare, Medicaid, Tricare, Workers Compensation, ICD-10, QA/QI, CMCN, CPHM, URAC, Clinical Research, Excel, Oracle, Citrix, Outlook