Open To Work
Ava Duke
HEALTHCARE OF AMERICA
Bowie,MD
Work Preference
Desired Job Title
Utilization Review NurseUtilization Review Manager
Work Type
Full Time
13
years of professional experience
Results-driven Utilization Review Nurse specializing in clinical documentation and care coordination. Enhanced patient outcomes through effective reviews and interdisciplinary collaboration, demonstrating strong analytical and interpersonal communication skills. Committed to driving compliance and improving patient outcomes across diverse healthcare settings.
Work History
Utilization Review Nurse
7 Years 9 Months- Conducted comprehensive utilization reviews to ensure compliance with healthcare regulations and standards.
- Collaborated with interdisciplinary teams to evaluate patient care plans and recommend necessary adjustments.
- Analyzed clinical data to identify trends, improving efficiency in resource allocation and patient outcomes.
- Facilitated communication between healthcare providers and insurance representatives to resolve complex authorization issues efficiently.
- 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.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Mitigated potential legal issues related to improper admission or discharge decisions by consulting with physicians regarding complex cases that required further clarification.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Performed admission reviews based for medical necessity based upon MCG GUIDELINES
Utilization Review Manager
4 Years 5 Months- Led utilization review processes to ensure compliance with healthcare regulations and policies.
- Developed strategies for improving care coordination and resource allocation among clinical teams.
- Mentored staff on best practices in utilization management and quality assurance standards.
- Analyzed data trends to identify opportunities for enhancing service efficiency and patient outcomes.
- Established relationships with providers to facilitate effective communication regarding patient care decisions.
- Collaborated with cross-functional teams to optimize patient care pathways and reduce unnecessary hospitalizations.
- Evaluated performance metrics to drive continuous improvement initiatives within the utilization review department.
- Managed department budgets, allocating funds appropriately for staffing needs, training initiatives, and technology updates.
- Ensured consistent application of admission criteria among team members through ongoing education and feedback sessions.
- Promoted a culture of continuous improvement by encouraging team members to actively participate in departmental process improvement initiatives.
- Maintained confidentiality of sensitive patient information while adhering to HIPAA regulations during the utilization review process.
- Facilitated productive relationships with stakeholders including physicians, nursing staff, case managers, social workers, payers, patients, families to promote a collaborative approach towards care coordination.
- Contributed to multidisciplinary meetings discussing appropriate level of care determinations, discharge planning and post-acute care services.
- Increased staff efficiency with effective delegation, supervision, and performance evaluation of team members.
- Performed admission reviews based on medical necessity based upon INTERQUAL CRITERIA specification.
Education
Master of Science - Nursing
- graduated with honors
Bachelor of Science - Nursing
Associate of Arts - Nursing Science
Skills
Utilization review
InterQual guidelines
Clinical documentation
Records analysis
Care coordination
Team collaboration
Interpersonal communication
Timeline
Utilization Review Nurse
HEALTHCARE OF AMERICA
11.2018 - CurrentRead More
Utilization Review Manager
Molina Healthcare
04.2013 - 09.2017Read More
University of Phoenix
Master of Science from Nursing
Read More
University of Phoenix
Bachelor of Science from Nursing
Read More
Prince George's Community College
Associate of Arts from Nursing Science
Read More