AIDA HERWIG
Dumont,NJ
Summary
Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
27
27
years of professional experience
1
1
Certification
Work History
RN /Operations Manager
Englewood Allergy & Associates
Englewood, NJ
01.2023 - 01.2024
- Collaborated with physicians in developing patient-specific treatment plans.
- Assessed patient health and developed individualized care plans accordingly.
- Carried out physician orders regarding tests or medication administration accurately and safely.
- Assisted doctors during medical procedures.
- Maintained thorough, accurate and confidential documentation in electronic medical records.
Utilization Review Nurse
Health First Health Insurance
New York, NY
12.2003 - 06.2006
- Identified opportunities for improvement within the utilization review process through data analysis.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Communicated with external partners such as managed care organizations or vendors on a regular basis.
- Facilitated communication between payers, providers and patients concerning authorization issues or concerns.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Provided education to providers regarding utilization management processes and protocols.
Director of Utilization Review
North General Hospital
New York, NY
07.1997 - 10.2003
- Assessed the appropriateness of medical services and procedures based on clinical documentation and criteria.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Contacted insurance carriers to obtain authorizations for services delivered to patients.
- Managed appeals for denied services, providing additional information to support medical necessity.
- Participated in interdisciplinary meetings involving case management, social work, physicians, nurses, and other members of the health care team.
- Ensured that all utilization reviews adhere to applicable state and federal laws as well as industry standards.
- Evaluated proposed treatments or services based on appropriateness, necessity, clinical efficacy, cost-effectiveness, and medical necessity guidelines.
Education
Bachelor of Science - Community Health Services
St. Joseph's College
Brooklyn06-1999
Associate of Science - Nursing
Helene Fuld College of Nursing
New York06-1994
Skills
- Utilization Management
- Interdepartmental Collaboration
- Documentation Review
- Decision-Making
- Process Improvement
- HIPAA Compliance
- Interdepartmental Functions Coordination
- Employee Recruitment and Hiring
Accomplishments
- Valedictorian
- Awarded with nine prestigious honors including excellence in both academic and clinical.
- IPRO Honorable Mention with Distinction Award for Outstanding Service to the Healthcare Community
Affiliations
- Baking is my passion!
- Sewing
- Zumba and Line Dancing
Certification
- New York RN License - 469659-1
- Certified Professional Utilization Review
References
References available upon request.
Timeline
RN /Operations Manager
Englewood Allergy & Associates
01.2023 - 01.2024
Utilization Review Nurse
Health First Health Insurance
12.2003 - 06.2006
Director of Utilization Review
North General Hospital
07.1997 - 10.2003
Bachelor of Science - Community Health Services
St. Joseph's College
Associate of Science - Nursing
Helene Fuld College of Nursing
- New York RN License - 469659-1
- Certified Professional Utilization Review
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