Utilization Review Registered Nurse at Centene, Superior Health Services (2023-03 – Present)
- Analyze health care needs to determine a patient's treatment plans.
- Perform initial and concurrent review of inpatient cases applying evidenced-based criteria (i.e. MCG / Interqual criteria)
- Discuss cases with facility healthcare professionals to obtain plans-of-care
- Collaborate with Medical Directors performing utilization management
- Participation in discussions with the Clinical Services team to improve the progression of care to the most appropriate level
- Consult with the Medical Director, as needed, for complex cases and make appropriate referrals to downstream partners
- Apply clinical expertise when discussing case with internal and external Case Managers and Physicians
- Identify delays in care or services and manage with Medical director
- Follow all Standard Operating Procedures in end to end management of cases
- Obtain clinical information to assess and expedite alternate levels of care
- Facilitate timely and appropriate care and effective discharge planning
- Maintain compliance with Federal, State and accreditation
Utilization Review Registered Nurse at Cigna (2016-09 – 2023-03)
- Perform initial and concurrent review of inpatient cases applying evidenced-based MCG criteria
- Discuss cases with facility healthcare professionals to obtain plans-of-care
- Participation in discussions with the clinical services team to improve the progression of care to the most appropriate level
- Consult with the Medical Director, as needed, for complex cases and make appropriate referrals to downstream partners
- Apply clinical expertise when discussing case with internal and external case managers and physicians
- Identify delays in care or services and manage with aligned Medical Director
- Follow all standard operating procedures in end-to-end management of cases
- Obtain clinical information to assess and expedite alternate levels of care
- Facilitate timely and appropriate care and effective discharge planning
- Maintain compliance with federal, state and accreditation organizations
- Identify opportunities for improved communication or processes
- Participate in audit activities and meetings.
Utilization Review Registered Nurse at Emblem Health (2012-09 – 2016-08)
- Perform initial and concurrent review of inpatient cases applying evidenced-based Interqual criteria
- Discuss cases with facility healthcare professionals to obtain plans-of-care
- Collaborate with Medical Directors performing utilization management
- Participation in discussions with the clinical services team to improve the progression of care to the most appropriate level
- Consult with the Medical Director, as needed, for complex cases and make appropriate referrals to downstream partners
- Apply clinical expertise when discussing case with internal and external Case Managers and Physicians
- Identify delays in care or services and manage with aligned Medical Director
- Follow all standard operating procedures in end-to-end management of cases
- Obtain clinical information to assess and expedite alternate levels of care
- Facilitate timely and appropriate care and effective discharge planning
- Maintain compliance with Federal, State and accreditation organizations
- Identify opportunities for improved communication or processes
- Participate in audit activities and meetings.
- Audited charts and reviewed clinical documents to verify accuracy.
- Collaborated with an interdisciplinary team to determine timely delivery of services.
- Referred clients to appropriate team members, community agencies and organizations to meet treatment needs.
