Bridget Guidice
Philadelphia,PA
Summary
Seeking a challenging position as a Registered Nurse in a remote setting with the opportunity to advance and grow within a field where I can utilize my skills.
Overview
20
20
years of professional experience
Work History
Utilization Management, Clinical Care Reviewer, Prior Authorization
Amerihealth Caritas
01.2018 - 03.2025
- Reviewed and processed prior authorization requests for outpatient and inpatient request for a variety of medical services, including medications, procedures, Durable medical equipment and diagnostic tests
- Assessing medical records to verify the appropriateness of requested services based on clinical guidelines and insurance Coverage
- Contacted healthcare providers to gather additional information or clarify details regarding members care
- Communicated authorization decisions to providers in a timely manner, explaining rationale for approvals or denials and sent letters
- Identifying potential issues with prior authorization requests and escalating to Medical Director when necessary
- Maintaining accurate documentation of review process and authorization decisions within the system
- Applying independent medical judgment to medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated
- Proficiency utilizing evidence based clinical decision support tools, such as InterQual
- Excellent communication, analytical, and critical thinking skills
- Detail oriented and strong organizational skills
- Demonstrated ability to prioritize and multi-task to ensure deadlines for deliverables are met
- Working knowledge of MS Office including Word, Excel, Outlook, Teams, Jiva and Internet applications in a Windows based environment
- Proficiency utilizing electronic medical record (EMR) and clinical documentation programs
- Demonstrated ability to work independently within a remote environment
- Complete medical necessity reviews for inpatient and outpatient services
- Collaborate with members and providers to collect necessary information for reviews
- Pend requests for additional information or clarification as needed
- Utilize independent medical judgment to evaluate requests against medical health benefit policies
- Authorize services and refer cases to the Medical Director when indicated
- Identify care coordination opportunities and refer cases to Population Health as necessary
- Maintain current knowledge of laws, regulations, and policies relevant to the role
Personal Health consultant, Care Manager, Clinical Care Reviewer- UM And case manager
Alere/ Optum
12.2009 - 12.2017
- Remotely monitored members electronically on CHF scale
- Educate patients telephonically through insurance companies on Congestive Heart Failure, Diabetes, COPD, CAD, Muscular skeletal pain and Management of medications
- Reviewed electronic medical health records and open care gaps to help keep patients out of the hospital to keep health care cost down using clinical knowledge and nursing experience
- Reviewed provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review
- Perform initial assessments and continued stay reviews utilizing InterQual and Milliman using evidenced-based criteria in order to identify and support the appropriate level of care
- Abstract data from a variety of medical records to ensure accurate clinical data
- Adhere to established quality, timeliness, and productivity outputs required in the completion of first level nursing utilization review
- Monitor patient via computer on their weights and symptoms
- Educate patients on chronic disease self management and knowledge of emergency care planning
- Encourage conversations about advance directives with patients and caregivers
- Conduct hospitalization risk assessments, teletriage and phone coaching
- Educate health care providers and patient/caregivers regarding the important features of patients condition
- Assist individuals/caregivers with preventing avoidable hospital admissions
- Work with specific Case Managers from the health plan and hospital that are assigned to the patient
- Identify and facilitate the use of specific community resources that may aid the patient, caretaker, and family in self management
- Experience in utilization review
- Refer cases to medical director for review
Administer
Mollen Clinic - Flu shots USA
09.2009 - 12.2009
- Administer influenza vaccine to patients
Private Duty Nurse for elderly
01.2008 - 12.2009
- Assist with ADL's including bathing, feeding, dressing, medication regimen and treatments
- Make Dr
- Appointments and handle insurance and medicare issues
Registered Nurse
Temple Northeastern Hospital
Philadelphia, PA
06.2005 - 01.2009
- Labor and delivery, post partum, ante partum, maternal and newborn care
- Continuous fetal monitoring and assisting Dr
- In deliveries
- Circulate and assist with cesarean sections in an operating room, assist physician with scalp spiral electrodes and IUPC
- Provide surgical recovery and cardiac monitoring in a PACU setting
- Head to toe newborn assessments, apgar scoring, monitoring newborn well-being, glucose monitoring, hearing screenings, and assist with circumcisions
- Administer medications, maintain and monitor patient analgesia including PCA, epidural and spinal
- Triage prenatal emergencies
- Insert and maintain I.V
- Therapy and heplocks
- Insert urethral catheterizations, maintain JP drains and dressing care
- Maintain contact with physicians regarding maternal and newborn care
- Provide and educate patients and family in prenatal, antepartum, post-op, postpartum, wound care and diabetic care
- Charge Nurse when applicable
Registered Nurse
CHOP- Kids First of Roxborough
Philadelphia, PA
01.2007 - 01.2008
- RN in pediatric office working under Doctors supervision for children ages birth to late adolescents
- Duties include assessment of sick and well children, weight checks, blood pressure, pulse, pulse ox, vision and hearing test, rechecks, nurse visits, immunizations, allergy shots, administration of medication, catheterizations, insurance checks, demographics, nebulizer treatments
- Running labs for finger/toe sticks for hemoglobin and lead, glucose testing, hemoccults, rapid strep tests, urine dipstick and pregnancy tests
- Providing education to patients and family
- Triage patients telephonically and personally
Registered Nurse
Lankenau Hospital
Wynnwood, PA
01.2005 - 09.2005
- Responsible for maternal and newborn care postpartum
- Duties include head to toe assessments, BP, pulse, respirations, medication administration, lab draws, maintaining I.V
- Therapy, and providing patient education on newborn and postpartum care
Education
Associate in Applied Science - Nursing
Montgomery County Community College
Blue Bell, PA01.2004
Skills
- Microsoft Word
- Excel
- Access
- Teams
- MS Office
- PowerPoint
- Outlook
- Interqual medical guidelines
- Milliman medical guidelines
- Written communication
- Oral communication
- Decision making
- Time management
- Prioritizing work
- Meeting deadlines
- Self-directed
- Ability to work independently
References
Available Upon Request
Timeline
Utilization Management, Clinical Care Reviewer, Prior Authorization
Amerihealth Caritas
01.2018 - 03.2025
Personal Health consultant, Care Manager, Clinical Care Reviewer- UM And case manager
Alere/ Optum
12.2009 - 12.2017
Administer
Mollen Clinic - Flu shots USA
09.2009 - 12.2009
Private Duty Nurse for elderly
01.2008 - 12.2009
Registered Nurse
CHOP- Kids First of Roxborough
01.2007 - 01.2008
Registered Nurse
Temple Northeastern Hospital
06.2005 - 01.2009
Registered Nurse
Lankenau Hospital
01.2005 - 09.2005
Associate in Applied Science - Nursing
Montgomery County Community College