BARBARA SMITH
Ashland
Summary
Healthcare professional with substantial experience in utilization review and patient care management. Known for precision in evaluating patient treatment plans and making critical decisions to optimize resource use. Valued team collaborator with focus on achieving impactful results and adapting to dynamic healthcare environments.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Behavioral Health Nurse
Foundations for Living
03.2024 - Current
- Enhanced interdisciplinary team collaboration through effective communication and coordination of patient care.
- Ensured compliance with regulatory standards by staying current on industry best practices, policies, and procedures.
- Participated in ongoing professional development opportunities to maintain clinical expertise and stay current on advancements in the field of behavioral health nursing.
- Reduced behavioral incidents by developing and implementing individualized patient treatment plans.
- Administered medications and assessed side effects, successes and failures of new medications.
MDS/Utilization Review Coordinator
Northwood Healthcare Group
01.2023 - 03.2024
- Supported positive working relationships between physicians, nursing staff, and other healthcare professionals through clear communication and collaboration on patient-centered goals.
- Set schedules for staff to start and complete MDS assessments and care plan meetings.
- Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
- Provided ongoing education to clinical staff on the importance of proper documentation for optimal reimbursement and compliance with regulations.
- Participated in external audits and surveys, providing documentation and insight to demonstrate the effectiveness of the utilization review program.
- Facilitated interdisciplinary team meetings to discuss patient progress, treatment plans, and coordination of care for improved outcomes.
- Evaluated medical necessity criteria using evidence-based guidelines to ensure that services provided were both clinically appropriate and cost effective.
- Enhanced patient care quality by conducting thorough utilization reviews and coordinating with healthcare providers.
- Identified potential areas of risk or non-compliance through regular audits, implementing corrective action plans as needed to mitigate concerns.
- Ensured compliance with regulatory guidelines by maintaining accurate documentation and records for all utilization review activities.
- Increased efficiency of the utilization review process through regular communication with insurance companies for timely authorizations.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed prior authorization review of services requiring notification.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
MDS RN Coordinator/Utilization Review Coordinator
Crystal Care Center of Ashland
04.2022 - 01.2023
- Maintain MDS schedule, be accessible to members of the IDT, and provide clear, updated information on completion deadlines.
- Schedule, complete, and transmit all MDS assessments to state database in a timely manner to ensure appropriate billing.
- In charge of Utilization Review process, investigating for maximum reimbursement, and ways to improve case mix.
- Complete daily skilled charting audits, weekly QM reports, triple check, and care plan audits.
- Streamlined workflows within the department by developing tools and resources aimed at improving consistency in utilization review practices.
MDS RN Coordinator
Arbors at Mifflin
10.2021 - 04.2022
- Maintain MDS schedule, be accessible to members of the IDT, and provide clear, updated information on completion deadlines.
- Schedule, complete, and transmit all MDS assessments to state database in a timely manner to ensure appropriate billing.
- Communicate with physicians, STNAs, Nurses, families, IDT, and residents regarding functional abilities and usual performance.
- Complete daily skilled charting audits, weekly QM reports, triple check, and care plan audits.
- Championed the importance of ethical decision-making within the Utilization Review Department, fostering an environment where all team members felt empowered to advocate for high-quality patient care.
Registered Nurse
University Hospitals
06.2013 - 10.2021
- Utilized strong assessment skills to determine necessary patient care in an 8-bed ICU
- Administered IV, oral, and injections of medications as directed, CRRT, assist with bedside procedures
- 1-year Charge Nurse experience
Education
Bachelor of Applied Science -
Chamberlain University
Downers Grove, IL01.2017
Skills
- MDS 30
- Utilization Review
- Prior Authorization
- Individualized care plans
- Discharge planning
- Teamwork and collaboration
- Word/Excel/PowerPoint
- EMR documentation
Certification
- Registered Nurse, State of Ohio
- Basic Cardiac Life Support (BCLS), American Heart Association
Timeline
Behavioral Health Nurse
Foundations for Living
03.2024 - Current
MDS/Utilization Review Coordinator
Northwood Healthcare Group
01.2023 - 03.2024
MDS RN Coordinator/Utilization Review Coordinator
Crystal Care Center of Ashland
04.2022 - 01.2023
MDS RN Coordinator
Arbors at Mifflin
10.2021 - 04.2022
Registered Nurse
University Hospitals
06.2013 - 10.2021
Bachelor of Applied Science -
Chamberlain University
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