Cynthia Adams
Verona,PA
Summary
Director of Case Management
Care Manager
Discharge plan manager
Utilization Review nurse consultant
Overview
10
10
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse Consultant
CVS/Aetna
07.2023 - 10.2023
- Responsible for utilization management services within the scope of licensure
- Conducts primary functions of prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals and execution of member/provider approval and/or denial letter
- Reviews provider requests for services requiring authorization
- Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts
- Manage appeals for services denied
- Responsible for written and/or verbal notification to members and providers
- Demonstrates proactive anticipatory discharge planning; serves as joint transition of care coordinator with case management and facilitates member care transition
- Ensures medical director written decision is consistent with criteria (CMS, MCG, state, medical policy, clinical criteria)
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards
RN Discharge Plan Manager
Supplemental Healthcare
UPMC Shadyside Hospital
07.2022 - 06.2023
- Work with patients throughout their treatment journey from day one of admission to post-discharge to ensure patients are prepared for a successful discharge and achieve continued improvement following inpatient care
- Advocate on behalf of patient/family/caregivers for access to services and for protecting the patient's health, well-being, safety, and rights
- Identify clinical, psychosocial, historical, financial, cultural, and spiritual needs that guide the planning process with the patient to attain optimal outcomes
- Complete detailed patient assessments to determine patients' capacity for self-care, identify support systems, outline barriers to discharge, and determine the likelihood that patients will require post-hospital services and the availability of those services
- Collaborate with a multidisciplinary team to coordinate an individualized, safe, efficient care plan
- Integrate patients' goals, the health care team's assessment, risks, and available resources to develop and coordinate a successful transition plan
- Serve as a liaison between patients and the care team
- Incorporate discipline-specific recommendations, test results, and outstanding orders into the discharge plan and respond to the progression of discharge milestone
- Maintain knowledge of resources in the area, their capabilities and capacities, and service providers available
- Ensure appropriate arrangements for post-hospital care will be made before discharge and work to avoid unnecessary delays in discharge
- Serve as a contact between hospitals and post-hospital care facilities and the physicians who provide care in both settings
RN Utilization Review Coordinator
Community Life
01.2022 - 07.2022
- Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements
- Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc
- Interprets clinical information provided or reviewed and works closely with RN Case Managers to ensure the Participant goals of care are known to the health care providers across the continuum and at each transition of care
- Interpret clinical information to support utilization protocols for authorizing inpatient services
Director of Case Manager
Harmervillage Care Center
01.2021 - 12.2021
- Perform verification of utilization criteria reviews Pre authorization, concurrent reviews and authorizations for post-acute services
- Build relationships and coordinate with payor sources to ensure proper reimbursement for facility provided services and to promote cost attentive care via a focus on resource management
- Demonstrate compliance with facility-wide Utilization Management policies and procedures
- Assures the department is identifying and negotiating the fullest possible reimbursement to maximize insurance benefit coverage for the patient
- Reviews insurance verification forms to minimize risk
RN Case Manager
Excalibur Insurance
05.2019 - 01.2021
- Coordinate in house utilization reviews of cases
- Conduct the initial assessment of the clients medical, vocational, and situational status to evaluate and recommend options for maximizing potential and improvement of outcomes
- Oversee the medical coordination by attending physician's appointments, addressing treatment options, diagnoses, prognosis, and capacity for work
Case Manager
Utilization Review RN Maxim Healthcare Services
01.2014 - 05.2019
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries
- Determined medical necessity and cost-effectiveness of services through utilization review processes
- Applied medical criteria and clinical judgment to researched cases to evaluate and establish determinations
- Worked with insurance companies and patients to determine best courses of action
- Conducted complex research, review and analysis of medical records, treatment plans and claim information
Discharge Plan Manager
Case Manager/Utilization Review Nurse Maxim Healthcare Services
01.2014 - 01.2014
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries
- Determined medical necessity and cost-effectiveness of services through utilization review processes
- Applied medical criteria and clinical judgment to researched cases to evaluate and establish determinations
- Worked with insurance companies and patients to determine best courses of action
- Conducted complex research, review and analysis of medical records, treatment plans and claim information
RN Case Manager
Excalibur Insurance
05.2019 - 01.2012
- Coordinate in house utilization reviews of cases
- Conduct the initial assessment of the clients medical, vocational, and situational status to evaluate and recommend options for maximizing potential and improvement of outcomes
- Oversee the medical coordination by attending physician's appointments, addressing treatment options, diagnoses, prognosis, and capacity for work
Education
Bachelorette - Nursing
Penn State New Kensington
New Kensington, PAAssociates - Nursing
Citizens School of Nursing
New Kensington, PA06.2014
Skills
- Critical care experience
- ICU experience
- Tube feeding
- IV insertion
- Case management
- Motivational interviewing
- Patient observation
- Patient assessment
Certification
RN License
Timeline
Utilization Review Nurse Consultant
CVS/Aetna
07.2023 - 10.2023
RN Discharge Plan Manager
Supplemental Healthcare
07.2022 - 06.2023
RN Utilization Review Coordinator
Community Life
01.2022 - 07.2022
Director of Case Manager
Harmervillage Care Center
01.2021 - 12.2021
RN Case Manager
Excalibur Insurance
05.2019 - 01.2021
RN Case Manager
Excalibur Insurance
05.2019 - 01.2012
Case Manager
Utilization Review RN Maxim Healthcare Services
01.2014 - 05.2019
Discharge Plan Manager
Case Manager/Utilization Review Nurse Maxim Healthcare Services
01.2014 - 01.2014
Bachelorette - Nursing
Penn State New Kensington
Associates - Nursing
Citizens School of Nursing