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Experienced Utilization Review Nurse with 15+ years of experience in high-volume environments along with a strong background within a variety of medical environments. Experienced in reviewing case and appeal information, ensuring regulatory guidelines are followed, and working closely with cross-functional teams. Equipped with a significant level of communication and interpersonal abilities in addition to a strong background in effectively fostering positive relationships with patients, co-workers, and multi-disciplinary medical teams.

Utilization Review Medicare Case Management Coaching/Training Patient Education

Patient Assessment/Triage Medication Administration Electronic Medical Records

Medicare Guidelines Regulatory Compliance JCAHO Standards Compliance

  Direct day to day administrative operations within a fast-paced environment with a focus on increasing productivity and operational efficiency levels

  Communicate with providers on a daily basis in regard to patient treatment plans, review clinical treatment plans, and utilize Interqual to identify inpatient criteria

  Respond quickly to utilization review specific inquiries and process prior authorizations which requires reviewing medical criteria

  Utilize superior communication and interpersonal abilities to maintain rapport with both the beneficiary and network provider

  Led medical review logistics within the organization which centered on reviewing and analyzing medical records along with reviewing medical decisions based on resources, Medicare policies, and abiding by regulatory guidelines

  Gathered and reviewed comprehensive medical information, made medical claim decisions based on available information, and processed cases in a timely manner

  Utilized several resources which included Medicare guidelines, local and national coverage determinations, CMS internet-only manuals, Medicare benefit policies, and HCPCS

  Played a lead role researching claims related to workman s compensation, short-term disability, long-term disability, and comprehensive pharmacy reviews

  Recognized as a Quality Assurance Nurse in regard to Physician reviews, pharmacy reviews, and medical reviews along with working with clients and generating reports decisions in regard to the continued disability of individuals

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  Completed the review of medical cases and appeals which centered on reviewing Medicare Part A appeal requests and responding to re-determinations requests

  Generated written responses in a timely manner and utilized the InterQual system, IOM, and CMS guidelines to analyze appeals

  Provided nursing and administrative support to patients within various hospitals throughout the Dallas and East Texas area

  Completed comprehensive patient exams, developed appropriate treatment plans, and administered patient medication

  Monitored patients for changes in medical status, worked closely with cross-functional medical teams, and responded to critical patient situations

  Oversaw nursing and hospital administration tasks within a specialty care hospital which included managing patient care and treatment plans

  Supervised a team of 10 RN s, 5 Nurse Technicians, and a Telemetry Technician within a 50-bed unit which required providing coaching/mentoring and handling escalated employee relations issues

  Member of the Clinical Practice Committee and Clinical Transformation Task Force

  Awarded the Five Star Spirit Award