April Israel
Orange Park
Summary
Highly experienced and dedicated Licensed Practical Nurse (LPN) with an active compact multistate license in Florida and has 16+ years of proven expertise in Utilization Management (UM) and Prior Authorization across prominent managed care organizations, including Centene and Aetna. Knowledge of audit processes and applicable state and federal regulations. Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines. Ability to collaborate effectively with team members and internal departments. Strong attention to detail with a focus on maintaining quality in all tasks. Strong verbal and written communication skills. Microsoft Office suite/applicable software program(s) proficiency.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Home health Nurse
Angels of Care Home Health
05.2025 - Current
- Provides skilled nursing care to children in their homes, often managing chronic illnesses, disabilities, or recovering from illness or injury.
- They assess patients, administer medications and treatments, educate families.
- Provided specialized medical care to children in their homes
- Address a range of needs from basic care to complex medical conditions.
- Assess, monitor, and treat patients and educate families.
- Strong clinical skills, the ability to work independently, and excellent communication and interpersonal skills.
UM/Prior Authorization Nurse
Centene
05.2023 - 12.2024
- Promoted the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
- Performed telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.
- Performed utilization management and prior authorization reviews for Medicare, Medicaid, and Commercial plans, ensuring compliance with Milliman (MCG), InterQual, ASAM criteria, CPB, and CMS guidelines.
- Completed medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.
- Collaborated with various staff within provider networks and case management team electronically or telephonically to coordinate member care.
- Educated providers on utilization and medical management processes.
- Provided clinical knowledge and act as a clinical resource to non-clinical team staff.
- Enter and maintain pertinent clinical information in various medical management systems. (e.g., CMS, MCGs, InterQual).
- Conducted 12–15 prior authorization reviews daily, including inpatient, outpatient, behavioral health, DME, and concurrent reviews.
- Reviewed a wide range of outpatient services such as occupational therapy (OT), physical therapy (PT), speech therapy (ST), outpatient rehab, drug rehabilitation, partial hospitalization (PHP), and cognitive behavioral therapy (CBT).
- Utilized clinical judgment to assess medical necessity and level of care for all requests, documenting decisions in accordance with organizational policies.
- Collaborated cross-functionally with provider networks, case management, and internal teams to coordinate member care and ensure continuity of services.
- Educated providers and internal non-clinical staff on utilization and medical management protocols.
- Maintained accurate clinical documentation in medical management systems to support regulatory compliance and quality assurance.
Realty Realtor
Crossview
03.2023 - Current
- Gathered, provided, and explained details of current market conditions, pricing, legal requirements, and similar information.
- Facilitated selling clients with pricing based on current market values.
- Assisted clients with staging properties for sale; hosted open houses and other promotional events.
- Sold over 2.5 million in volume
Relator
Veterans United Reality
02.2021 - 03.2023
- Gathered, provided, and explained details of current market conditions, pricing, legal requirements, and similar information.
- Assists selling clients with pricing based on current market values.
- Assists clients with staging properties for sale; hosts open houses and other promotional events.
Utilization Review Nurse/Pre-Authorization
Aetna/ CVS
07.2006 - 01.2021
- Utilized clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Conducted utilization management and pre-authorization reviews for various plans using MCG (Milliman), InterQual, ASAM criteria, and CMS guidelines to ensure medical necessity and regulatory compliance.
- Processed and completed an average of 20 prior authorization reviews daily, including inpatient, outpatient, behavioral health, DME, and concurrent reviews.
- Reviewed various outpatient services including occupational therapy (OT), physical therapy (PT), speech therapy (ST), outpatient rehab, substance abuse treatment, drug rehab programs, partial hospitalization (PHP), and cognitive behavioral therapy (CBT).
- Utilized clinical acumen and evidence-based criteria to evaluate the appropriateness of care and level of service requested; collaborated with medical directors for escalated cases.
- Gathered and analyzed clinical documentation to make timely and accurate coverage determinations in accordance with policies, procedures, and regulatory standards.
- Acted as a liaison between providers and internal departments to support continuity of care and ensure service coordination across the healthcare continuum.
- Identified quality improvement and cost-containment opportunities while supporting benefit utilization strategies.
- Provided consultation and subject matter expertise to internal stakeholders regarding UM protocols and benefit management processes.
- Maintained precise documentation in UM systems to support audit readiness and ensure compliance with state and federal requirements.
- Gathered clinical information and apply the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination and recommendation along the continuum of care.
- Communicated with providers and other parties to facilitate care and treatment.
- Identified opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
- Consulted and lent expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Education
LPN Program -
First Coast Technical Institute
Medical Secretary Diploma -
Concorde Career Institute
Skills
- Utilization Review
- Prior Authorization
- Precertification
- Case Management
- Disease Management
- HIPPA
- Healthcare Effectiveness Data
- Information Set (HEDIS)
- State and federal regulatory compliance
- Team Player
Certification
- Licensed Practical Nurse (LPN), Multistate License
- Real Estate Sales Associate
Timeline
Home health Nurse
Angels of Care Home Health
05.2025 - Current
UM/Prior Authorization Nurse
Centene
05.2023 - 12.2024
Realty Realtor
Crossview
03.2023 - Current
Relator
Veterans United Reality
02.2021 - 03.2023
Utilization Review Nurse/Pre-Authorization
Aetna/ CVS
07.2006 - 01.2021
LPN Program -
First Coast Technical Institute
Medical Secretary Diploma -
Concorde Career Institute