CHERYL TAYLOR
Madison
Summary
Dynamic Utilization Review Nurse with extensive experience at Ascension Wisconsin, specializing in regulatory compliance and denial management. Adept at leading multidisciplinary teams to enhance care coordination and successfully implement MCG guidelines. Notable for leveraging critical thinking and effective communication to drive improved patient outcomes and operational efficiency in complex healthcare environments.
Overview
20
20
years of professional experience
Work History
UTILIZATION REVIEW NURSE
ASCENSION WISCONSIN
MILWAUKEE
12.2021 - Current
- Responsible for first level reviews, concurrent reviews, initial denial management, and collaborating with payers to ensure timely authorization management for a tertiary facility
- Knowledgeable of Medicare, Medicaid, and Commercial payers regulations and/or contracting requirements for Ascension WI
- Expertise with both MCG and InterQual and the inpatient only list for Medicare, Medicaid, and Tricare
- Expertise with working closely with Physician advisors in the day to management of secondary reviews and denial management
DIRECTOR OF CARE MANAGEMENT/UTILIZATION MANAGEMENT
ASCENSION WISCONSIN
MILWAUKEE
07.2017 - 12.2021
- Oversight of 23 hospitals consisting of urban hospitals, critical access hospitals, and joint venture hospitals
- Oversight of 140-150 RN case managers, Social Workers, UM nurses, and administrative associates
- Collaborated with the VP of Clinical Services to roll out a Physician Advisor Program along with a centralized UM Hub
SUPERVISOR OF CLINICAL SERVICES (UTILIZATION MANAGEMENT)
MOLINA HEALTHCARE
MILWAUKEE
09.2016 - 06.2017
- Oversight of 11 associates in the Wisconsin Market along with the day-to-day management of NCQA metrics such as turnaround times and provider notifications
- Developed and implemented productivity standards along with performance standards and auditing tools to assist with process improvement during quarterly coaching
DIRECTOR OF CARE MANAGEMENT
WHEATON FRANCISCAN INC.
MILWAUKEE
09.2014 - 09.2016
- Oversight of 3 hospitals (including a safety net hospital within the inner city), oversight of our inpatient renal program in partnership with DaVita, and the Transitions of Care Program
- Managed the day-to-day operations including tracking and trending LOS, GMLOS/Excess days, Avoidable days, readmission metrics, Dialysis metrics, and metrics from the Transitions of Care Program
CLINICAL CASE MANAGER
WHEATON FRANCISCAN INC.
MILWAUKEE
02.2014 - 09.2014
- RN case manager on the cardiac unit
- High-risk assessments & management of SDOH
- PCP appointments
- Discharge f/u calls
- HF education
- Discharge planning with assessment
- Management of a complex and vulnerable population with limited resources
SUPERVISOR OF CARE MANAGEMENT
WHEATON FRANCISCAN INC.
MILWAUKEE
10.2012 - 02.2014
- Oversight of 3 hospitals (including a safety net hospital within the inner city)
- Responsibility for the day-to-day operations and monitoring of complex issues
- Responsible for over 50 associates
- Oversight of RN case managers, social workers, clinical documentation specialists, ED case managers, and transition of care case managers
- Managed daily rounds and LOS meetings
- Onboarding and coaching of all associates
- Collaboration with interdisciplinary team
RN CASE MANAGER/LEAD CASE MANAGER
WHEATON FRANCISCAN INC.
St. Joseph Hospital
11.2009 - 10.2012
- Worked as an RN case manager on a medical-surgical unit in a dyad model, with a combination of discharge planning and utilization review, using the Milliman guidelines for medical necessity determinations.
- Served as a preceptor and subject matter expert after about 16 months.
- Transitioned to the Lead Case Manager at the request of the Director of Case Management.
TELEPHONIC UTILIZATION REVIEW NURSE
INDEPENDENT PHYSICIANS NETWORK
12.2008 - 11.2009
- Responsible for utilization review and providing care coordination, as warranted, to ensure safe and timely discharges for vulnerable patients with managed Medicaid.
- Third Party Administrator for Managed Medicaid Providers.
UR NURSE/CASE MANAGER
UNITEDHEALTHCARE
03.2005 - 12.2008
- Responsible for daily onsite utilization reviews at 3 large hospital systems along with care coordination as needed
- Use of Milliman guidelines
- Transitioned to telephonic case management of the complex Medicaid population after 2 years
Education
BACHELOR OF SCIENCE - NURSING
UNIVERSITY OF WISCONSIN MILWAUKEE
Milwaukee05.1989
HEALTH ADMINISTRATION -
UNIVERSITY OF ST. FRANCIS
Joliet, ILSkills
- Ability to Multitask
- Ability to Work Under Pressure
- Ability to Work in a Team
- Leadership Skills
- Dedicated team player
- Critical Thinking
- Utilization review
- Medical necessity determination
- Regulatory compliance
- Epic charting
- MCG guidelines
- InterQual criteria
- Denial management
- Care coordination
- Data analysis
- Interdisciplinary collaboration
- Team leadership
- Effective communication
- Utilization management
- Insurance verification
- HIPAA compliance
- Interpersonal and written communication
- Managed care
- Patient transfers and transitions
- Outpatient care
- Communication
- Records analysis
- Prior authorization
- Documentation and reporting
- Healthcare regulations
- Compliance procedures
- Discharge planning coordination
- Performing assessments
- Medicare
- Inpatient care
- Telephonic nursing
- Medicaid
- Active listening
- Interpersonal communication
- Acute care expertise
- Time management abilities
- Acute and rehabilitative care
- Oxygen saturation standards
- Problem-solving abilities
- Analytical thinking
- Time management
References
References available upon request.
Timeline
UTILIZATION REVIEW NURSE
ASCENSION WISCONSIN
12.2021 - Current
DIRECTOR OF CARE MANAGEMENT/UTILIZATION MANAGEMENT
ASCENSION WISCONSIN
07.2017 - 12.2021
SUPERVISOR OF CLINICAL SERVICES (UTILIZATION MANAGEMENT)
MOLINA HEALTHCARE
09.2016 - 06.2017
DIRECTOR OF CARE MANAGEMENT
WHEATON FRANCISCAN INC.
09.2014 - 09.2016
CLINICAL CASE MANAGER
WHEATON FRANCISCAN INC.
02.2014 - 09.2014
SUPERVISOR OF CARE MANAGEMENT
WHEATON FRANCISCAN INC.
10.2012 - 02.2014
RN CASE MANAGER/LEAD CASE MANAGER
WHEATON FRANCISCAN INC.
11.2009 - 10.2012
TELEPHONIC UTILIZATION REVIEW NURSE
INDEPENDENT PHYSICIANS NETWORK
12.2008 - 11.2009
UR NURSE/CASE MANAGER
UNITEDHEALTHCARE
03.2005 - 12.2008
BACHELOR OF SCIENCE - NURSING
UNIVERSITY OF WISCONSIN MILWAUKEE
HEALTH ADMINISTRATION -
UNIVERSITY OF ST. FRANCIS
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