AMY MENKE
ANKENY
Summary
Focused RN with 20+ total years in medical care delivers consistent and professional work for every assignment. Offers 10 years in Utilization Management industry and top-notch abilities in being a detail-oriented team player with strong organizational skills, deliver 95% and above accuracy on audit scoring. Ability to handle multiple projects simultaneously with a high degree accuracy. Trained in Prior Auth & CCR review/Managed Care: Medicare, Medicaid, and Commercial coverage. Experienced in EMR, InterQual & MCG. Unrestricted Compact State Iowa Registered Nursing License with ability to transfer RN license to different state if required. Working knowledge of Word, Excel, PowerPoint and strong typing skills.
Registered Nurse with extensive experience in utilization management, skilled in evaluating medical records and clinical documentation against established criteria such as InterQual and MCG. Demonstrated ability to assess the appropriateness of proposed treatments and coordinate care by collaborating with healthcare providers to ensure compliance with regulatory standards. Proven track record of identifying care gaps and implementing policies that enhance patient outcomes while adhering to strict timelines for review processes. Committed to maintaining accurate documentation and facilitating effective communication among interdisciplinary teams to optimize patient care delivery.
Overview
20
20
years of professional experience
Work History
RN, UM Prior Authorization Nurse Reviewer Medicare
Centene
Texas
07.2025 - Current
- Evaluating medical records, doctor's notes, and lab results against standardized criteria (using InterQual or MCG, Corporate Policies, Medicare LCD/NCD) to approve or escalate requests.
- Deciding if a proposed surgery, medication, or diagnostic test is the most appropriate and cost-effective level of care.
- Communicating with physician offices to gather missing clinical documentation or explain coverage requirements.
- Referring complex cases that do not meet standard criteria to a Medical Director (physician) for a final denial or peer-to-peer review.
- Ensuring all reviews are completed within strict state and federal regulatory timelines to prevent delays in patient care.
- (Limited contract: A1 Staffing)
RN, UM Inpatient Care Concurrent Review Nurse Medicaid
AmeriHealth Caritas
Harrisburg
02.2024 - 06.2025
- Maintained accurate documentation of utilization reviews conducted in accordance with regulatory requirements.
- Identified gaps in care and recommended interventions to improve patient outcomes.
- Implemented policies and procedures aimed at reducing length of stay without compromising quality of care provided.
- Consulted with physicians regarding clinical criteria for appropriate level of care determinations.
- Evaluated post-acute care options for patients, including rehabilitation facilities, skilled nursing facilities, and home health care agencies.
- Developed relationships with community partners to facilitate referrals and coordination of care.
- Reviewed medical records to determine appropriateness of treatment and services.
- Ensured compliance with federal, state, accrediting agency, payer source regulations as well as internal policy guidelines during each review process.
- Harrisburg, PA
RN, INPATIENT CARE MANAGER
United Healthcare Group
Minnetonka
12.2017 - 01.2024
- Managing inpatient level of care patients from admit through discharge.
- Reviewing cases for medical necessity, reviewing inpatient clinical criteria via InterQual.
- Evaluation of treatment options.
- Gauging patient progress via clinical updates from facilities.
- Coordination of care with other providers.
- Placing discharge referrals as appropriate to meet patient needs post acute.
- Consistently met requirements with scores of 95% and above for case management reviews.
- Provided accurate inpatient level of care reviews, meeting required 24 hour turn around times.
- Interaction with hospital care managers to ensure their patients receive the care they need.
- Minnetonka, MN
CLINICAL CARE NURSE REVIEWER/PRIOR AUTHORIZATION, UM
AmeriHealth Caritas
Des Moines
04.2016 - 11.2017
- Contacted providers to obtain information and records needed to conduct comprehensive clinical review of case and final determination.
- Determined and authorized services for patients in accordance with guidelines and regulations.
- Reviewed and documented relevant information into data system applications.
- Review and completed requests for authorization for specific medications, treatments or surgeries, and consider each prior authorization request.
- Des Moines, IA
CORRECTIONS NURSE
Corizon Health Services
Des Moines
04.2012 - 04.2016
- Stabilized prisoners suffering from falls, stab wounds or other injuries prior to hospital transfer.
- Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
- Administered different therapies and medications in line with physician orders and treatment plan.
- Complied with all security regulations within prison system and administered care in safest possible environment.
- Des Moines, IA
MED SURG RN
Iowa Methodist Medical Center
Des Moines
06.2013 - 09.2013
- Started intravenous fluids, administered medications, and documented patient charts by recording food and fluid output and intake.
- Educated patients and families on medical-surgical procedures, therapeutic regimens, and pain management techniques.
- Assisted with wound care, dressing changes and NG tube placement to maintain stable patient conditions.
- Des Moines, IA
PEDIATRIC HOME HEALTH NURSE
Ultimate Nursing
Le Mars
09.2011 - 04.2012
- Provided compassionate nursing care to medically fragile children in home settings.
- Handled medication administration, ventilation monitoring and wound care.
- Communicated with patients and family members, providing detailed information regarding care and medications.
- Tracked patients' progress through careful reporting and documentation at each visit.
- Le Mars, IA
Education
Associate Degree - Nursing Science
Iowa Lakes Community College
Emmetsburg, IALPN - Practical Nursing
Iowa Lakes Community College
Emmetsburg, IASkills
- Microsoft Excel
- Adaptability and Flexibility
- Attention to Detail
- Great communication
- Time-management skills
- Critical thinking skills
- Ability to manage stress
- Commitment to career development
- Prioritization
- Utilization review
- Medical necessity evaluation
- InterQual criteria
- Cost-effective care
- Utilization management
- MCG guidelines
- Clinical documentation
- Care coordination
- Medicare compliance
- Medicaid compliance
- Patient assessment
- Medical necessity determination
- Regulatory compliance
- Discharge planning
- Treatment evaluation
- Care gap identification
- Electronic health records
- Communication with providers
- Documentation accuracy
- Nursing best practices
- Ethical practice
- Interdisciplinary collaboration
- Policy adherence
- Patient confidentiality
- Clinical assessment
- Healthcare systems
- Healthcare regulations
- Needs assessment
- Performing assessments
- Physician consultations
- Managed care
- Interpersonal and written communication
- Discharge planning coordination
- Milliman guidelines
- Communication
- HIPAA compliance
- Compliance procedures
- Home health care
- Patient care plans
- Documentation and reporting
- Insurance verification
- Medicaid
- Outpatient care
- Prior authorization
- Medicare
- Inpatient care
- Patient transfers and transitions
- Decision-making
- Accurate documentation
- Microsoft office
- Problem-solving
- Wound dressing
- Chronic disease management
- Collecting vitals
- Patient consultation
- Goal setting
- IV therapy management
- Professional demeanor
- Interpersonal skills
- Pediatric emergency assessment, recognition and stabilization (PEARS)
- Well visit procedures
- Pain management
Languages
English, Native
Timeline
RN, UM Prior Authorization Nurse Reviewer Medicare
Centene
07.2025 - Current
RN, UM Inpatient Care Concurrent Review Nurse Medicaid
AmeriHealth Caritas
02.2024 - 06.2025
RN, INPATIENT CARE MANAGER
United Healthcare Group
12.2017 - 01.2024
CLINICAL CARE NURSE REVIEWER/PRIOR AUTHORIZATION, UM
AmeriHealth Caritas
04.2016 - 11.2017
MED SURG RN
Iowa Methodist Medical Center
06.2013 - 09.2013
CORRECTIONS NURSE
Corizon Health Services
04.2012 - 04.2016
PEDIATRIC HOME HEALTH NURSE
Ultimate Nursing
09.2011 - 04.2012
Associate Degree - Nursing Science
Iowa Lakes Community College
LPN - Practical Nursing
Iowa Lakes Community College