Amanda Schertz BSN, RN
Fishers,IN
Summary
Accomplished Utilization Management Nurse with a proven track record at Evolent, enhancing patient care through expert utilization of MCG and InterQual. CMS- NCD/LCD criteria. Skilled in clinical assessment and care coordination, I have significantly contributed to quality improvement initiatives. My ability to maintain patient confidentiality and ensure accurate clinical documentation has consistently supported team success and compliance.
Overview
35
35
years of professional experience
Work History
Utilization Management Nurse
Evolent
02.2015 - Current
- Serving as one of the primary nurse reviewers for IUH Medicare Advantage program for Indiana University Health since 2015 performing utilization review for inpatient admissions, outpatient surgeries, DME, and ancillary services.
- Determine medical necessity and appropriateness of services using clinical review criteria. MCG, InterQual, CMS-NCD/LCD guidelines.
- Appropriately identifies and refers cases that do not meet established criteria to the Medical Director.
- Performs accurate data entry, collaborates with Claims, Quality Management and Provider Relation Departments as requested.
- Provides assistance to manager with running reports, and coverage when manager is absent.
- Supported cost containment efforts by identifying over-utilization trends and recommending strategies for improvement.
- Strengthened relationships with community resources by networking, attending meetings, and establishing collaborative partnerships.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Ensured compliance with regulatory guidelines by staying current on industry standards and participating in ongoing education opportunities.
- Promoted a positive work environment by mentoring new nurses and serving as a resource for clinical questions and concerns.
- Contributed to team success by consistently meeting productivity goals while maintaining high-quality standards in job performance.
- Maintained up-to-date knowledge of payer-specific guidelines to ensure accurate authorizations for medically necessary services.
- Coordinated seamless transitions of care across multiple settings including acute care hospitals, rehabilitation facilities, and home care services.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
Case Manager II
Northside Hospital Atlanta
06.2011 - 10.2014
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
- Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Enhanced communication between clients and providers through consistent follow-ups and progress updates.
- Advocated for client rights when interacting with external agencies or institutions, ensuring fair treatment at all times.
- Contributed to team discussions and case conferences actively, sharing insights and expertise with colleagues to optimize client support strategies.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
Senior Nurse Case Manager
Anthem, Inc.
11.2006 - 06.2011
- Optimized cost savings for healthcare facilities by minimizing unnecessary services and ensuring appropriate utilization of resources.
- Managed complex cases involving multiple chronic conditions while balancing competing demands on time-sensitive projects such as discharge planning.
- Streamlined case management processes for enhanced efficiency and optimal resource allocation.
- Leveraged strong communication skills in advocating for patient needs with insurance companies, healthcare providers, and community organizations.
- Conducted thorough assessments of patients'' physical, psychosocial, and financial needs to inform appropriate interventions and resources.
- Collaborated with healthcare providers to drive continuity of care.
Assistant Director of Clinical Services
TLC Staff Builders
06.2005 - 11.2006
United Home Care
Director of Nursing
04.2005 - 06.2005
Clinical Manager Home Infusion
Unity Point Health
04.2001 - 03.2005
Infusion Nurse Case Manager
Unity Point
09.1997 - 04.2001
Staff and Charge Nurse
Unity Point Methodist Hospital
07.1995 - 09.1997
LPN
Unity Point Methodist
08.1993 - 01.1994
Graduate Nurse
Mercy Medical Center Des Moines
08.1993 - 01.1994
Health Care Technician/CNA
Unity Point Lutheran Hospital
09.1989 - 09.1992
Education
Bachelor of Science - Nursing
Grand View University
Des Moines, IA1992
Skills
- Registered Nurse with BSN
- Proficient with MCG, InterQual, CMS- NCD/LCD criteria
- Clinical assessment
- Care Coordination
- Quality Improvement
- Patient confidentiality
- Accurate clinical documentation
Timeline
Utilization Management Nurse
Evolent
02.2015 - Current
Case Manager II
Northside Hospital Atlanta
06.2011 - 10.2014
Senior Nurse Case Manager
Anthem, Inc.
11.2006 - 06.2011
Assistant Director of Clinical Services
TLC Staff Builders
06.2005 - 11.2006
United Home Care
Director of Nursing
04.2005 - 06.2005
Clinical Manager Home Infusion
Unity Point Health
04.2001 - 03.2005
Infusion Nurse Case Manager
Unity Point
09.1997 - 04.2001
Staff and Charge Nurse
Unity Point Methodist Hospital
07.1995 - 09.1997
LPN
Unity Point Methodist
08.1993 - 01.1994
Graduate Nurse
Mercy Medical Center Des Moines
08.1993 - 01.1994
Health Care Technician/CNA
Unity Point Lutheran Hospital
09.1989 - 09.1992
Bachelor of Science - Nursing
Grand View University