Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

April Anderson

Hebron,Ohio

Summary

Insightful Utilization Review Nurse recognized for high productivity and efficiency in task completion. Excels at medical necessity reviews, care coordination, and regulatory compliance, ensuring optimal patient outcomes and streamlined hospital operations. Possess specialized skills in critical thinking, case management, and healthcare policy interpretation. Thrive using empathy, communication, and problem-solving to navigate complex healthcare environments and foster collaborative relationships with healthcare professionals.

Overview

18
18
years of professional experience
1
1
Certification

Work History

Prior Authorization LPN

IRI CVS Caremark Contract
Hebron, Ohio
12.2024 - 04.2025
  • Managed inbound phone calls and fax requests, utilizing courteous and professional behavior in line with established standards.
  • Sorted incoming faxes to ensure compliance with departmental and client-specific requirements.
  • Processed and triaged prior authorization (PA) and appeal requests using eligibility systems to determine request type.
  • Created, routed, and completed PA and appeal cases in accordance with federal, client, and state-mandated guidelines.
  • Reviewed criteria-based prior authorizations, following internal policies and procedures.
  • Referred cases that do not meet clinical criteria to pharmacists or medical directors.
  • Provided internal nursing support to the PA team and member services department.
  • Maintained complete, timely, and accurate documentation for all case activities and communications.
  • Communicated PA status to physician offices, pharmacies, and members.
  • Oversaw fax processing and provided telephone assistance to prescriber office staff, pharmacies, and members.
  • Assisted with outbound phone calls, and monitored and responded to inquiries in shared mailboxes.
  • Collaborated with pharmacists, clinical colleagues, healthcare professionals, and members to ensure accurate and timely case resolution.
  • Followed all PA procedures to ensure that each request was processed accurately.
  • Maintained compliance with HIPAA, ERISA, CMS, and client-specific regulatory requirements.
  • Assessed patient medical records to determine the appropriateness of requested services and procedures.
  • Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
  • Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues.
  • Managed appeals for denied services, providing additional information to support medical necessity.
  • Interpreted and evaluated diagnostic tests to identify and assess patient's condition.
  • Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
  • Analyzed utilization data to identify patterns and make recommendations for cost-effective care delivery.
  • Contacted insurance carriers to obtain authorizations for services delivered to patients.
  • Educated healthcare providers on utilization review processes, criteria, and best practices.
  • Maintained up-to-date knowledge of changes in healthcare regulations, policies, and evidence-based practices.
  • Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
  • Performed pre-certification, concurrent, and retrospective reviews of inpatient and outpatient services.
  • Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
  • Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
  • Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
  • Utilized evidence-based guidelines to support utilization review decisions and recommendations.
  • Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.

Billing Specialist LPN

Elumina Health
07.2024 - 10.2024
  • Managed billing inquiries telephonically and facilitated intake of The Ohio State University's Home Health referrals.
  • Facilitated insurance review and prior authorization to perform intake and verify benefits and eligibility using Epic, Care Link, Outlook, and Availity.
  • Performed telephonic coordination of care, discharge planning, and digital charting.
  • Reviewed clinical documentation for purpose of medical necessity, prior authorization, and appeals.
  • Provided Verbal and Email Communication of insurance denials, approvals, and benefit limitations to patients and clinicians.
  • Reviewed and verified insurance information and eligibility.
  • Communicated with patients regarding billing inquiries and resolved discrepancies.
  • Followed up on unpaid claims and addressed denials or rejections.
  • Maintained organized records of billing documents and patient accounts.
  • Assisted in coding procedures and diagnoses for billing purposes.
  • Collaborated with healthcare providers to gather necessary documentation.
  • Ensured compliance with relevant regulations and billing guidelines.
  • Provided support during audits and financial reviews.

Clinical Analyst

Clinix Healthcare
10.2022 - 08.2024
  • Reviewed clinical documentation to determine the medical necessity of the prior authorization request for treatments, medications, and procedures, per ODG MCG criteria, insurance, and state guidelines.
  • Referred complex medical and pharmacy procedures and treatments to Physician Review, adhering to timeliness, quality, and URAC guidelines.
  • Worked independently processing prior authorization requests, utilizing critical thinking skills, excellent communication skills, leadership skills, and organizational skills.
  • Maintained confidentiality and compliance adhering to the Health Insurance Portability and Accountability Act (HIPAA) when reviewing medical documentation, requesting clinical information, or when providing Utilization Review determination in written format.
  • Reviewed twenty-five to thirty concurrent and retrospective reviews daily for medical necessity, appropriate claim duration, and prior authorization. Reviews involved outpatient, inpatient, pharmacy, and durable medical equipment clinical review of documentation.

Patient Care Advocate

Quantum Health
04.2022 - 10.2022
  • Provided telephonic customer service to Quantum Health members.
  • Provided benefits for education, benefit interpretation, and resolution for billing inquiries and issues.
  • Advocated for patients and assisted in prior authorization, referrals, benefit exclusions and limitations, and provided education to facilitate efficient navigation of the healthcare system.
  • Assisted patients in selecting plans that best meet their medication needs, and financial considerations.
  • Educated patients about their benefits, including coverage gaps, catastrophic coverage, and out-of-pocket costs.
  • Helped patients navigate cost-saving strategies, such as preferred pharmacies, and mail-order options.
  • Provided patients and their families with information about their health conditions, treatment options, and self-care strategies.
  • Educated patients on medication management, lifestyle modifications, and preventive healthcare practices.
  • Served as a liaison between patients, healthcare providers, insurance companies, and other stakeholders to ensure clear and effective communication.
  • Coordinate referrals to specialists or other healthcare providers as necessary, ensuring timely access to care.

First Level Utilization Review

AIG/ Health Direct
12.2014 - 04.2022
  • Demonstrated proficiency in reviewing clinical documentation, determining medical necessity, and ensuring compliance with insurance guidelines and policies, utilizing ODG, MCG, and MTUS criteria and guidelines.
  • I reviewed thirty to forty concurrent and retrospective reviews daily for the medical necessity of workers' compensation duration and prior authorization, revolving around outpatient/ inpatient care, pharmaceuticals, and durable medical equipment
  • Communicated effectively with healthcare providers, managing prior authorization processes.
  • Maintained fax processing, provided telephone call assistance, and maintained accurate documentation, as outlined in the job description.
  • Advocated for patients' access to necessary services, and navigating the non-certification and appeals process.
  • Multitasked, prioritized, and adapted to a challenging environment, along with digital charting and working within call center environments.
  • Exhibited excellent communication skills, both written and verbal, and the ability to navigate Microsoft Office products and proprietary computer systems efficiently.
  • Exceeded accuracy and quality standards, working independently, and remotely.
  • Established positive work relationships, effectively contributing to team members, providers, and non-medical staff.
  • Provided clear and concise nursing rationale to support criteria-based documentation and communication of medical services, benefits, and prior authorization determinations.
  • Maintained accurate and detailed patient records, including assessments, care plans, and progress notes. Ensuring compliance with regulatory standards and documenting interactions with patients and healthcare providers.
  • Communicated with healthcare providers to gather additional information or clarify clinical details related to the prior authorization request.
  • Assisted with claims and reimbursement issues.
  • Provided ongoing education to patients and healthcare providers about updates that may impact medication coverage and costs.
  • Monitored and optimized healthcare resource allocation, ensuring cost-effective and quality care delivery.

Disability Specialist 3

Sedgwick CMS
New Albany, Ohio
09.2013 - 07.2014
  • Reviewed clinical documentation to determine medical necessity, appropriate duration of disability payment, treatment, and procedures conducted per federal and employer guidelines.
  • Responsible for referring complex clinical and medical procedures requested to the medical director for review per URAC, quality, and timeliness guidelines.
  • Provided responsive and professional customer service to healthcare providers, addressing inquiries, concerns, and requests related to utilization review and disability/leave processes.
  • Monitored and optimized healthcare resource allocation, ensuring cost-effective and quality care delivery.
  • Maintained accurate records of all interactions with healthcare providers and insurance companies. This includes documenting details of authorization requests, clinical information reviewed, decisions made, and communications conducted via calls, emails, phone, and fax.
  • Advocated for patients by ensuring they receive necessary care and services, while managing costs effectively.
  • Worked independently processing prior authorization requests by utilizing critical thinking skills, excellent communication skills, leadership skills, and organizational skills.
  • Reviewed medical coding and supporting documentation to build disability claims, and leave of absence claims.
  • Utilized the nursing process and critical thinking skills to determine the appropriate duration management of the claim.

Licensed Practical Nurse

Interim Home Health
Newark, Ohio
06.2012 - 09.2013
  • Operated as a Licensed Practical Nurse for patients in Licking County. Key job functions included medication administration, vital sign assessment, and wound care in a home care setting.

Customer Service Representative

Aetna
New Albany, Ohio
08.2007 - 09.2009
  • Responded to customer inquiries via phone, email, or fax communication.
  • Resolved issues promptly and effectively. This includes addressing billing questions, product inquiries, service complaints, and technical support needs.
  • Educated customers about products, services, and policies. This involves explaining features, benefits, pricing, and terms of use to help customers make informed decisions.
  • Updating and maintaining customer accounts, and contact information in the database. Keeping accurate records of interactions and transactions to track customer issues and resolutions.
  • Escalated complex or unresolved customer issues to the appropriate departments or supervisors for further investigation and resolution. Following up to ensure prompt resolution and customer satisfaction.
  • Delivered exceptional customer service experiences by demonstrating empathy, patience, and professionalism.

Education

Licensed Practical Nurse Diploma -

Fortis College Columbus
Westerville, Ohio

Skills

  • Epic charting
  • Insurance verification
  • Prior authorization
  • Medical coding
  • Clinical documentation
  • Patient advocacy
  • Data analysis
  • Effective communication
  • Problem resolution
  • Critical thinking
  • Organizational skills
  • Team collaboration
  • Office equipment operation
  • Deadline oriented
  • Confidentiality
  • Time management
  • Deadline adherence
  • Computer literacy
  • Microsoft office
  • InterQual Criteria/ Milliman Care Guidelines
  • Medical billing /Insurance expertise
  • Utilization review
  • Healthcare compliance
  • Customer service
  • Attention to detail
  • Health promotion
  • Patient record review
  • Protocol review
  • Claims management
  • Care coordination
  • Data management
  • Excellent communication
  • Analytical
  • Benefit education
  • Problem-solving aptitude
  • telephonic nursing
  • Healthcare regulations
  • Professional demeanor
  • Communication
  • Electronic health records
  • Test interpretations

Certification

· Fortis College Columbus- Westerville, Ohio Licensed Practical Nurse Diploma- Completed with 3.44 Honors with GPA 3.44

· LPN Licensure in State of Ohio #145323. MEDS. IV issued 07/31/2011-expires 10-31-2026

Timeline

Prior Authorization LPN

IRI CVS Caremark Contract
12.2024 - 04.2025

Billing Specialist LPN

Elumina Health
07.2024 - 10.2024

Clinical Analyst

Clinix Healthcare
10.2022 - 08.2024

Patient Care Advocate

Quantum Health
04.2022 - 10.2022

First Level Utilization Review

AIG/ Health Direct
12.2014 - 04.2022

Disability Specialist 3

Sedgwick CMS
09.2013 - 07.2014

Licensed Practical Nurse

Interim Home Health
06.2012 - 09.2013

Customer Service Representative

Aetna
08.2007 - 09.2009

Licensed Practical Nurse Diploma -

Fortis College Columbus

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April Anderson