April Israel
Orange Park,FL
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
20
20
years of professional experience
1
1
Certification
Work History
Home Health Nurse
Angels of Care Home Health
04.2025 - 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.
- Administered medication and treatments according to care plans and physician orders.
- Monitored patient vital signs and reported significant changes to healthcare team.
- Educated patients and families on health management, medication adherence, and preventive care strategies.
- Collaborated with interdisciplinary teams to develop individualized care plans for optimal patient outcomes.
- Implemented infection control protocols to ensure patient safety and hygiene standards were met consistently.
- Conducted comprehensive assessments to evaluate patient needs and progress towards health goals.
- Streamlined documentation processes, enhancing accuracy and efficiency in patient record-keeping systems.
- Developed strong rapport with patients and families, fostering trust and open communication during challenging times.
- Educated patients and families on disease management, medication safety, and at-home healthcare strategies to promote selfcare.
- Contributed to the overall success of the home health agency by maintaining high levels of patient satisfaction and positive outcomes.
- Documented patient vitals, behaviors, and conditions to communicate concerns to supervising nurse.
- Provided physical assessments, medication, and chronic disease management to home health patients.
- Delivered high-quality in-home nursing services, maintaining a safe and comfortable environment for patients.
- Coordinated with other healthcare team members to support patient needs.
- Identified early warning signs of patient deterioration or complications, promptly notifying physicians to adjust treatment plans accordingly.
- Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
- Conducted regular follow-up visits to monitor patient progress and make adjustments to care plans as needed.
- Collaborated with multidisciplinary healthcare teams to implement comprehensive treatment plans, ensuring continuity of care.
- Assessed patients' health status and developed individualized care plans to suit needs.
- Administered different therapies and medications in line with physician orders and treatment plan.
- Administered medications and treatments as prescribed by physicians.
- Assisted patients with activities of daily living to promote independence.
- Streamlined communication between healthcare providers, patients, and families by acting as a liaison for all parties involved in the care process.
- Provided compassionate care for patients with chronic illnesses, alleviating stress and promoting optimal wellness.
- Implemented effective infection control measures within the home setting, reducing risk of illness transmission among family members.
- Provided emotional support and kind companionship to patients and families to increase overall wellness.
- Served as a reliable resource for families seeking guidance on navigating complex healthcare systems and advocating for their loved ones'' needs.
- Managed patient medical records accurately and confidentially, ensuring compliance with HIPAA regulations.
- Improved patient outcomes by conducting thorough health assessments and developing personalized care plans.
- Supported patients'' mental and emotional well-being through active listening and empathetic communication during difficult periods of illness or recovery.
- Optimized patient comfort by addressing individual physical, emotional, spiritual needs during end-of-life care.
- Educated patients and families on disease processes, medications and treatments.
- Performed skilled nursing procedures such as tracheostomy care maintenance under physician supervision when required.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
Realty Realtor
Crossview
02.2023 - 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
- Guided clients through buying and selling processes to ensure smooth transactions.
- Conducted market analysis to identify trends and inform pricing strategies.
- Developed comprehensive marketing plans utilizing digital platforms to enhance property visibility.
- Negotiated contracts effectively, achieving favorable terms for clients while maintaining compliance.
UM/Prior Authorization Nurse
Centene
04.2023 - 11.2024
- 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.
- Evaluated prior authorization requests for medical services and treatments to ensure compliance with policies.
- Collaborated with healthcare providers to clarify clinical information and expedite authorization processes.
- Reviewed patient records and documentation for accuracy, ensuring timely processing of authorizations.
- Worked closely with case managers to facilitate appropriate utilization of healthcare resources through the prior authorization process.
- Collaborated with healthcare providers to ensure accurate submission of required documentation for timely authorizations.
- Provided exceptional customer service to both patients and healthcare professionals, addressing concerns related to the prior authorization process.
- Educated patients on their insurance benefits, helping them understand their coverage and limitations regarding specific procedures or medications.
- Promoted a culture of continuous improvement within the Prior Authorization department by regularly reviewing processes and making recommendations for optimization.
- Proactively identified potential barriers to approval, implementing strategies to address these challenges before they impacted patient care.
- Improved patient satisfaction by providing clear communication regarding insurance approvals and denials.
- Enhanced patient care by assessing insurance coverage and obtaining prior authorization for medical procedures.
- Expedited urgent requests for prior authorization, ensuring timely access to critical medical treatments.
- Maintained detailed records and documentation related to prior authorization requests, ensuring accurate tracking and reporting for both internal and external stakeholders.
- Ensured accurate data entry into electronic health record systems, resulting in improved tracking of prior authorization statuses.
- Conducted thorough reviews of medical records, identifying necessary documentation to support prior authorization requests.
- Assisted in maintaining compliance with changing regulations and policies by staying up-to-date on industry trends and best practices.
- Demonstrated commitment to professional development by participating in ongoing training opportunities related to the field of Prior Authorization nursing.
Relator
Veterans United Reality
01.2021 - 02.2023
- 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.
- Negotiated contracts with buyers and sellers, achieving favorable terms for clients while maintaining compliance.
- Developed marketing strategies to promote listings, increasing visibility across multiple platforms.
- Conducted market analyses to determine property values, providing clients with accurate pricing recommendations.
- Streamlined transaction processes, enhancing efficiency and reducing time from listing to closing.
Utilization Review Nurse/Pre-Authorization
Aetna/ CVS
06.2006 - 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.
- Conducted comprehensive reviews of clinical documentation to ensure medical necessity and compliance with guidelines.
- Evaluated treatment plans for appropriateness, recommending modifications based on patient needs and evidence-based practices.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Performed prior authorization review of services requiring notification.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and follow-up.
- Performed admission reviews based for medical necessity based upon Milliman nterQual, ASAM criteria, and CMS guidelines specification.
- Collaborated with healthcare providers to facilitate timely authorizations and prevent delays in patient care services.
- Analyzed utilization data to identify trends, implementing strategies that improved resource allocation within the organization.
- Performed admission reviews based for medical necessity based upon InterQual, ASAM criteria, and CMS guidelines specification.
- Conducted thorough evaluations of medical necessity for procedures, leading to optimal resource utilization.
Education
LPN Program - LPN
First Coast Technical Institute
Saint Augustine, FL03.2004
Medical Secretary Diploma - Health Care Administration
Concorde Career Institute
Jacksonville, FL02.1994
Skills
- Clinical utilization review
- Pre-approval processing
- Pre-certification coordination
- Client case management
- Chronic disease management
- HIPAA compliance knowledge
- Data-driven healthcare assessment
- HEDIS data analysis
- Regulatory compliance expertise
- Collaborative team member
Certification
- Licensed Practical Nurse (LPN), Multistate License
- Real Estate Sales Associate
Timeline
Home Health Nurse
Angels of Care Home Health
04.2025 - Current
UM/Prior Authorization Nurse
Centene
04.2023 - 11.2024
Realty Realtor
Crossview
02.2023 - Current
Relator
Veterans United Reality
01.2021 - 02.2023
Utilization Review Nurse/Pre-Authorization
Aetna/ CVS
06.2006 - 01.2021
LPN Program - LPN
First Coast Technical Institute
Medical Secretary Diploma - Health Care Administration
Concorde Career Institute