• Utilization Review Nurse with expertise in Prior Authorization review, inpatient
review, and behavioral health utilization review. Proficient in MCG guidelines for utilization management and well-versed in LOCUS, CALOCUS, and LOCADTR criteria for level of care determinations. Skilled in evaluating medical necessity, ensuring compliance with clinical guidelines, and
collaborating with healthcare providers to optimize patient care and resource
- Monitoring, assessing, planning, Implementing and evaluating patients care plan
- Administering medication, providing postoperative care and update patients medical chart
- Collaborating with interdisciplinary teams for optimized patient treatment plans and outcomes
- Promoting a safe and comfortable healing environment by addressing patient concerns promptly and professionally
- Educating patients on disease management, self-care techniques, and wellness strategies to improve long-term health outcomes
- Provided emotional support to patients' family members during critical incidents, strengthening overall trust in the healthcare team
- 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.
- Mitigated potential legal issues related to improper admission or discharge decisions by consulting with physicians regarding complex cases that required further clarification.
- Performed prior authorization review of services requiring notification.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
- 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.
- Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
- Increased staff efficiency by providing ongoing education on proper documentation techniques necessary for accurate claims processing.
- Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
- Supervised and maintained all utilization review documentation through Software.
- Enhanced patient satisfaction by collaborating with interdisciplinary teams to develop individualized care plans, ensuring appropriate level of care.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
- Promoted positive outcomes with proactive assessment of patients'' needs and development of targeted interventions to address identified barriers to recovery.