Casey Kisner
Grain Valley
Summary
Detail-oriented Utilization Review Nurse with strong clinical judgment. Proficient in InterQual and MCG criteria and documentation, ensuring compliance and optimal resource utilization. Ready to enhance patient care and streamline processes. Over 40 years of Nursing including Utilization Review, Case Management, Hospice, Home Health, Med-Surg, and Psychiatric.
Overview
12
12
years of professional experience
Work History
Utilization Review Nurse
CVS
01.2024 - 03.2024
- Conducted comprehensive reviews of patient treatment plans for medical necessity.
- Collaborated with healthcare providers to ensure adherence to utilization management guidelines.
- Documented utilization review findings in compliance with regulatory standards. Utilized Interqual and MCG criteria.
- Maintained up-to-date knowledge of insurance policies and healthcare regulations.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- 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.
Utilization Review Nurse
Optum, UnitedHealth Group
06.2017 - 04.2022
- 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.
- 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.
- Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
- Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
- Maintained all utilization review documentation through various EMR Platforms.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient's unique circumstances.
- Performed admission reviews based on medical necessity utilizing MCG and Interqual Criteria.
Utilization Review Nurse
Aetna
02.2012 - 06.2017
- Documented utilization review findings in compliance with regulatory standards. Utilized MCG and Interqual.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Maintained all utilization review documentation through various EMR Platforms.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
- Facilitated compliance with federal and state regulations, maintaining high standards of healthcare delivery.
- Conducted thorough evaluations of medical necessity for procedures, leading to optimal resource utilization.
- Reduced unnecessary medical costs, ensuring treatments met established medical guidelines and policies.
- Recorded details regarding therapies to keep patient charts updated.
- Collaborated with healthcare providers to ensure adherence to utilization management guidelines.
Education
Diploma Nurse - Nursing
Methodist Hospital School of Nursing
Memphis, TNSkills
- InterQual and MCG criteria
- Documentation and reporting
- Utilization review
- Records analysis
- Prior authorization
- HIPAA compliance
- Insurance verification
- Discharge planning coordination
- Managed care
- Telephonic nursing
- Medicare
- Patient transfers and transitions
- Time management
- Attention to detail
- Problem-solving abilities
- Multitasking
- Critical thinking
- Strong clinical judgment
- Organizational skills
- Adaptability and flexibility
- Electronic health records
- Documentation
- Discharge planning
- Communication
Timeline
Utilization Review Nurse
CVS
01.2024 - 03.2024
Utilization Review Nurse
Optum, UnitedHealth Group
06.2017 - 04.2022
Utilization Review Nurse
Aetna
02.2012 - 06.2017
Diploma Nurse - Nursing
Methodist Hospital School of Nursing