Amy Durrah
Frisco,TX
Summary
Versatile Division Manager bringing a 22-year career in nursing and reimbursement knowledge. Dynamic leader and analytical problem-solver with a keen understanding of patient needs and contractual guidelines. Remarkable strength of vision with extensive experience in performance and productivity improvements.
Overview
14
14
years of professional experience
Work History
Utilization Management Nurse
Signature HealthCARE
Louisville, k, KY
03.2021 - Current
- Assessed patient eligibility for services and benefits according to insurance policies and guidelines.
- Conducted utilization reviews, concurrent reviews, authorization requests and discharge planning.
- Collaborated with healthcare providers to ensure appropriate level of care was provided in a cost-effective manner.
- Interpreted data from claims systems to identify trends in utilization patterns for quality improvement initiatives.
- Reviewed appeals related to denied or reduced reimbursement decisions.
- Maintained knowledge base on current coding practices, government regulations, payer requirements.
Divisional Director of Managed Care
CommuniCare Inc.
Columbus, OH
06.2019 - 03.2021
- Divisional Director of Managed Care for 40 + buildings in Ohio, Kentucky, Pennsylvania and West Virginia.
- Developed a precertification department and role education and tracking tools for department.
- Maintain vast knowledge in review analysis and change in contracts
- Completes detailed financial analysis for individual plans
- Maintain monthly predictor and final financial analysis reports
- Implemented improved outcomes for financial reimbursement based on patient needs
- Educated at corporate and building level managed care practices for best use of contracts based on patient needs and Medicare/ Medicaid guidelines
- Lead and managed a team of Case Managers /Utilization to work closely together to learn from one another's knowledge with in their regions
- Complete oversite of Managed Care/ Utilization team for best patient advocacy and financial analysis based on contracts
- Increased revenue in company both rate/ contribution margin/ exclusions/ etc
- Assisted Vice President of Managed Care with contracting renewal opportunities for better reimbursement
- Assessment and proposal of allocations for budgeting within department. Scheduling of Managed Care delegations
- Completion and oversite of precertification, concurrent reviews, claim analysis, appeal processes, and authorization analysis
Senior Manager of Managed Care
CommuniCare Inc.
Columbus, OH
04.2017 - 06.2019
- Developed case management plans that incorporated medical necessity criteria from payers and other resourcesto advocate for patient needs and safety..
- Provided education about health plan coverage and benefit options to patients and families.
- Interpreted data from claims systems to identify trends in utilization patterns for quality improvement initiatives.
- Analyzed prior authorization requests for accuracy and completeness before submission to payer.
- Reviewed appeals related to denied or reduced reimbursement decisions.
- Participated in interdisciplinary team meetings to facilitate development of individualized care plans.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
Home Health Nurse
Mount Carmel Home Care
Columbus, OH
02.2016 - 04.2017
- Provided home health care services such as wound care, medication administration, and IV therapy.
- Assessed patient health by conducting physical examinations and evaluating medical histories.
- Educated patients and families about disease management, lifestyle changes, nutrition, and preventive healthcare measures.
ADON
Lutheran Home Society
Sandusky, OH
07.2010 - 12.2015
- Lead of multiple categories including infection control, wound care, psychotropic medications, QAPI, Risk management, Care Conferences, Managed Care, MDS, Utilization Management, and Audits
- Assisted in the development of clinical competency programs for staff.
- Participated in interdisciplinary team meetings to discuss patient care issues.
- Ensured compliance with state and federal regulations related to nursing practice.
- Collaborated with other ADONs to develop and implement policies and procedures.
Education
RN -
Fortis College of Nursing
Westerville, OH01.2020
LPN -
Ehove Adult Career Center
01.2002
Skills
- Corporate Communications
- Logistics Management
- Cross-functional team leadership
- Profit and loss statements
- Staff Training and Development
- Performance Improvement
- Project Management
- Financial Management
- Quality Improvement
- Utilization Management
Affiliations
- Community involvement, art, music, dance.
Accomplishments
- Earned Deans list in nursing school, numerous leadership roles throughout my career for communication, team building, ideals, ambition and educational practices.
References
References available upon request.
Timeline
Utilization Management Nurse
Signature HealthCARE
03.2021 - Current
Divisional Director of Managed Care
CommuniCare Inc.
06.2019 - 03.2021
Senior Manager of Managed Care
CommuniCare Inc.
04.2017 - 06.2019
Home Health Nurse
Mount Carmel Home Care
02.2016 - 04.2017
ADON
Lutheran Home Society
07.2010 - 12.2015
RN -
Fortis College of Nursing
LPN -
Ehove Adult Career Center