L J

Registered Nurse with 28+ years of healthcare experience and 8+ years in utilization review, case management, clinical documentation specialist, medical necessity review, appeals, and denial prevention. Experienced performing admission, concurrent, continued-stay, retrospective, and transitional-care reviews using InterQual/MCG; differentiating observation versus inpatient status; and communicating clinical rationale to physicians, hospitalists, facility staff, Physician Reviewers, and Medical Directors. Completes 35–40 reviews and supports 10–20 appeals daily across Medicare, Medicaid, Commercial, and Medi-Cal populations while meeting expedited turnaround, documentation, HIPAA, CMS, NCQA, and payer requirements.

Remote Utilization Review Nurse - Common Spirit Health (Contract) - California—Remote

(2026-01 - 2026-06)

• Performed admission, concurrent, continued-stay, and retrospective inpatient reviews using InterQual criteria to evaluate medical necessity, severity of illness, intensity of service, and appropriate level of care.
• Reviewed clinical documentation in Epic, Cerner, and XSOLIS Dragonfly; maintained clear, defensible determinations and follow-up updates within payer and regulatory turnaround times.
• Collaborated in real time with attending physicians, hospitalists, case managers, CDI, coding, and revenue-cycle teams to obtain missing clinical information and communicate clinical rationale.
• Identified cases requiring special handling and escalated adverse or complex determinations to Physician Reviewers/Medical Directors; supported peer-to-peer preparation and denial prevention.
• Completed approximately 35–40 reviews daily for Medicare, Medicaid, Commercial, and Medi-Cal populations while protecting PHI and meeting quality, productivity, and compliance expectations.

RN Case Manager / Utilization Review Nurse — Level I Trauma Center - Regional One Health - Memphis, TN

(2025-03 - 2025-07)

• Conducted concurrent and continued-stay reviews for complex trauma, medical, surgical, and critical-care admissions using InterQual/MCG and payer-specific criteria.
• Partnered with physicians, hospitalists, nursing, therapy, social work, and payers to resolve medical-necessity questions, remove discharge barriers, and support appropriate status and level-of-care decisions.
• Coordinated transitions to skilled nursing facilities, inpatient rehabilitation, LTACH, home health, hospice, infusion, DME, and community services; tracked length of stay, avoidable delays, and readmission risk.
• Prepared clinical summaries, appeals, peer-to-peer documentation, and follow-up communications; referred unresolved and high-risk cases through established escalation pathways.

RN Clinical Educator - IQVIA - Remote / Field-Based

(2024 - 2025)

• Delivered evidence-based clinical education to healthcare professionals, reinforced safe practice and program requirements, and documented interactions accurately and confidentially.
• Coordinated multiple priorities independently, addressed provider questions, and supported quality and compliance initiatives across diverse clinical settings.

RN Utilization Review Nurse - UnitedHealthcare - Remote

(2024 - 2024)

• Reviewed inpatient and outpatient requests for medical necessity, benefit alignment, and appropriate level of care using evidence-based criteria and health-plan policies.
• Communicated with providers to clarify clinical information, documented determinations, met standard and expedited timeframes, and referred cases requiring physician review.
• Applied Medicare, Medicaid, Commercial, state, federal, HIPAA, and quality requirements while delivering responsive provider customer service.

RN Utilization Review Supervisor - North Mississippi Medical Center - Mississippi

(2024 - 2024)

• Oversaw daily utilization review workflow, resource management, case escalation, documentation quality, and consistent application of medical-necessity criteria.
• Collaborated with nursing management, physicians, case management, and revenue-cycle partners to address status concerns, prevent denials, and meet regulatory deadlines.
• Served as a clinical resource for staff, monitored workflow priorities, identified quality concerns, and supported policy, compliance, and process-improvement updates.

RN Utilization Review Nurse / Lead Case Manager - Select Specialty Hospital - Acute Care / LTACH

(2021 - 2022)

• Led utilization review and case management for medically complex LTACH patients, completing admission and continued-stay reviews and coordinating post-acute transitions.
• Communicated clinical rationale with physicians, facility teams, payers, and families; facilitated authorizations, peer-to-peer reviews, appeals, discharge planning, and denial resolution.
• Maintained timely case documentation, tracked length of stay and care progression, and escalated clinical, quality, or coverage concerns appropriately.

Quality Assurance Review Nurse / Utilization Review Nurse - Managed Care Concepts - Managed Care

(2017 - 2019)

• Performed utilization and quality reviews, assessed medical necessity and documentation compliance, and applied client policies and payer-specific requirements.
• Identified quality-of-care and documentation issues, communicated findings to providers and leadership, and supported education, corrective action, and consistent review practices.
• Protected confidential health information and maintained accurate records in accordance with HIPAA and program standards.

Staff RN / Charge RN / Clinical Leadership - Progressive Health Hospital of Marks and Multiple Acute-Care Organizations

Extensive inpatient experience across Emergency, Behavioral Health, ICU/CCU, PACU, Medical-Surgical, Transplant, and other acute-care services. Assessed complex patients, coordinated multidisciplinary treatment, educated patients and families, supported safe transitions, and developed the clinical judgment required for evidence-based utilization determinations.

Doctor of Nursing Practice (DNP) - Nursing - Walden University

Master of Healthcare Administration (MHA) - Healthcare Administration - Belhaven University

Bachelor of Science in Nursing (BSN) - Nursing - Christian Brothers University

Bachelor of Arts (BA) - Arts - University of Mississippi