Susan Avila
Registered Nurse (RN) with 25+ years of clinical expertise in utilization reviews and case management
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About
Highly analytical and dedicated Registered Nurse with over 25 years of comprehensive expertise in clinical utilization reviews, retrospective medical record auditing, quality improvement, and case management. Proven track record executing complex evaluations of hospital and nursing facility records to validate medical necessity, diagnostic/procedural coding accuracy, and compliance with federal guidelines and Texas Medicaid rules (STAR, STAR+PLUS). Skilled at working under limited supervision with considerable latitude for independent judgment to identify potential fraud, waste, and abuse (FWA).
Proficient in use of personal computers and Microsoft software suites to meet stringent performance metrics within fast-paced telework/remote environments.
Experience
Patient Care Coordinator - Bella Grace Aesthetics and Wellness - Austin, TX
(2022-01 - 2024-12)
- Navigated multiple complex online health programs and electronic systems daily within a fast-paced environment, ensuring precise data entry and care coordination.
- Demonstrated strong quality leadership and clinical independent judgment to manage daily office operations, protocols, and multi-tasking administrative functions.
Clinical Supervisor - Austin NeuroCare - Austin, TX
(2010-01 - 2015-12)
- Served as a clinical expert to provide staff leadership, education, and development functions aimed at promoting high-quality, legally compliant, and cost-effective healthcare delivery.
- Reviewed and summarized comprehensive new patient records, abstracting precise medical history and clinical data into EMR systems under limited supervision.
- Executed utilization management by performing strict preauthorization assessments for requested radiology procedures, validating clinical necessity and documentation accuracy.
Field Case Manager - Evercare / United Health Plans - Austin, TX
(2010-01 - 2010-12)
- Conducted rigorous patient clinical assessments, utilizing independent judgment to develop comprehensive care plans and perform specialized utilization reviews.
- Ensured strict adherence to state policies, procedures, and regulatory guidance while documenting client clinical profiles and submitting critical funding paperwork to the state.
- Interacted professionally with Texas Medicaid providers, external healthcare agencies, and internal team stakeholders to coordinate continuity of care.
Quality Improvement Coordinator and Case Manager - Superior Health Plans - Austin, TX
(2009-01 - 2010-12)
- Performed clinical reviews of quality-of-care complaints submitted by Texas Medicaid (STAR / STAR+PLUS) members to ensure healthcare system integrity.
- Assured full, strict compliance with NCQA, state, and corporate regulatory measures during all review workflows.
- Executed preauthorization and utilization reviews of requested procedures, checking clinical necessity and documentation standards against Medicaid parameters.
Quality Improvement Coordinator and Case Manager - Associated Neurological Specialties - Austin, TX
(2009-01 - 2010-12)
- Managed telephone triage and patient education in a high-volume neurology environment, optimizing clinical assessment protocols to achieve excellence in quality standards.
Assistant Director / Program Review Specialist - Texas Medical Foundation - Austin, TX
(1997-01 - 2006-12)
- Conducted extensive retrospective reviews and quality monitoring for physician and facility corrective action plans, identifying systemic operational deficiencies and compliance gaps.
- Supervised nursing staff performing utilization reviews, quality-of-care audits, and complaint reviews, covering complex Medicare and Texas Department of Insurance (TDI) Workman's Compensation cases.
- Evaluated medical records to validate the delivery of quality care, medical necessity, and adherence to established contractual, state, and federal regulatory rules.
- Drafted highly complex, detailed summary reports detailing individual review findings for medical cases, effectively communicating technical data to oversight committees.
- Collaborated with external healthcare providers, state stakeholders, and internal colleagues to implement methodologies that minimized waste, enhanced plan effectiveness, and preserved HIPAA standards.
- Strategized with OIG stakeholders when investigating Medicare fraud and abuse.
Nurse Consultant - Texas Medical Foundation - Austin, TX
(2007-01 - 2009-12)
Supervisor – Health Care Services - Foundation Health Federal Services - Austin, TX
(1993-01 - 1997-12)
- Recruited, trained, and managed review nurses in the technical execution of utilization reviews, medical record auditing, and case management across Texas and Louisiana (Region 6 Tricare).
- Directed internal quality monitoring initiatives to evaluate nursing staff auditing accuracy, developing corrective action plans to remedy identified utilization management gaps.
Review Coordinator - Texas Medical Foundation - Austin, TX
(1990-01 - 1993-12)
- Executed detailed retrospective and concurrent utilization reviews for Medicare and Workman's Compensation cases to confirm accurate coding and medical necessity.
Clinical Nurse Advisor - Nutri-System Weight Loss Center
Charge Nurse - Brown's School Alternative Living Center
Staff Nurse / Charge Nurse - Asbury Hospital and Central Texas Oncology
Education
Bachelor of Science - Nursing - Marymount College
