Experienced Utilization Review Nurse with 8+ years of experience and a significant background in progressive roles within the medical industry. Experienced in reviewing complex healthcare claims, training third-party medical office staff members, and leading cross-functional teams. Equipped with a keen ability to manage large-scale projects, implement process improvements, and foster positive rapport with vendors, patients, co-workers, and members of executive management.

  Directed day to day administrative and nursing operations within a fast-paced environment with a focus on increasing productivity and patient satisfaction levels

  Reviewed complex patient cases and developed appropriate treatment plans, conducted medical necessity reviews, and ensured compliance with standard operating procedures

  Maintained an expert level knowledge of both HEDIS and Interqual in addition to ensuring Medicare and/or Medicaid guidelines were consistently followed

  Supported patients within a community health center which included coaching patients on disease management and health best practices

  Performed initial patient assessments in order to identify a diagnosis, created comprehensive treatment plans, promoted appropriate self-care practices, and provide referrals to community services based on individual patient needs

  Oversaw utilization review functions within the organization which centered on consistently monitoring, evaluating, and modifying treatment plans based on patient s changing medical needs

  Performed treatment evaluations to monitor quality levels, acted as a subject matter expert in regards to Medicare/Medicaid, and conducted prior authorization screening for home health patients

  Utilized superior communication and interpersonal abilities to build positive rapport with both patients and their families

  Oversaw the completion of detailed onsite medical record reviews within Provider offices with the goal of ensuring compliance with coding/billing practices, service delivery, and patient quality

  Identified, analyzed, and resolved complex member complaints, coached office staff members on appropriate coding/billing, and trained individuals on the HEDIS system

  Played a lead role in identifying potential operational risks within the office, completed annual medical record evaluations, and updated a database with appropriate case information

  Directed nursing operations within a home health environment which included evaluating patients for changes in medical status, assisting with self-care, and creating treatment/care plans

  Updated patient medical records with changes in medical history, initiated new medication orders, and maintained a significant knowledge of OSHA best practices