Cheryl McCauley
Bowie,MD
Summary
Accomplished Utilization Review Nurse with a proven track record by enhancing patient care through expert clinical assessments, Medicare and Medicaid knowledge. Excelled in records analysis and interpersonal communication, significantly contributing to team support and efficient healthcare service delivery. Skilled in coordinating discharge planning, and ensuring optimum health outcomes.
Overview
9
9
years of professional experience
Work History
Utilization Review Nurse
CVS/AETNA
Remote
03.2024 - Current
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Provided internal nurse support to PA team and member services department. Referred cases unable to meet clinical criteria to pharmacists and MD teams.
Utilization Review Nurse
Bright Health
Remote
04.2021 - 09.2023
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Obtained authorizations from multiple insurance carriers for various levels of care.
Utilization Review Nurse
Centene, Superior Health Services
Remote
06.2016 - 01.2021
- Assisted providers with identifying appropriate options for levels of care that could assist members in achieving optimum health stability.
- Prepared reports and data analysis via Microsoft Powerpoint to assist with NCQA accreditation audits.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
Utilization Review Nurse
Evergreen Health
Baltimore, MD
11.2015 - 06.2016
- Determined if the inpatient setting requested for surgery and/or medical care is appropriate.
- Identified diagnosis and determined need for continuing hospitalizations while monitoring the LOS as per established guidelines and professional judgment.
- Distinguished members at high risk for complicated medical treatment plans, and/or repeat admissions potential and referred them to the appropriate case and disease management teams
Education
LPN License-Maryland Board of Nursing - Nursing
Hannah Harrison For Career Education Nursing
Washington, DC09.2002
Skills
- Medicaid knowledge
- Records analysis
- Discharge planning coordination
- Clinical assessment
- Interpersonal and written communication
- Accountable Care/Managed Care Utilization Review/Clinical Workflow Improvement
- Medicare Quality Reporting for ACO Measures/GPRO Reporting
- Clinical Documentation Improvement/Utilization Review and Auditing
- EHR Clinical Documentation/Workflow improvement (McKesson, Practice Fusion, eClinicals)
- Medical Claims and Billing
- Population health management/Care Coordination for health plans and physician offices
Timeline
Utilization Review Nurse
CVS/AETNA
03.2024 - Current
Utilization Review Nurse
Bright Health
04.2021 - 09.2023
Utilization Review Nurse
Centene, Superior Health Services
06.2016 - 01.2021
Utilization Review Nurse
Evergreen Health
11.2015 - 06.2016
LPN License-Maryland Board of Nursing - Nursing
Hannah Harrison For Career Education Nursing