Susan (Suzi) Nelson

As part of a team that oversees six care delivery organizations UM and CM departments by monitoring compliance. Work closely with internal and external auditors to ensure compliance is met and maintained per state and federal guidelines. Organize, lead, and participate in all audits for several health plans.

• Review all levels of appeals for accuracy
• Contact clients and authorized representatives to provide appeal determinations
• Work closely with expert reviewers to ensure accuracy of determination
• Train new staff and assist with onboarding process
• Work closely with most major insurance companies to ensure determinations are provided in a timely manner according to URAC and jurisdictional guidelines
• Ensure that TAT are met.

• Review prior authorization request for medical necessity using national and state guidelines (MCG, eVicore, and InterQual)
• Write and audit Notice of Action letters
• Ensure that TAT are met.

• Responsible for coordination of subjects participating in a clinical research trial for breast cancer
• Provided educational material, phlebotomy, coordinated follow-up visits.

• Liaison between veterans administration (Northern Region), communicating with healthcare providers to provide superior customer service, easy and convenient access to healthcare
• Scheduled veterans with appropriate physicians based on symptoms and past medical history
• Created authorizations based on medical necessity.

• Screened potential candidates for participation in research studies
• EKG, Phlebotomy, vital signs, telehealth follow up, and telephone screenings.

• Perform a variety of bedside care practices for children under the direction of a physician
• Phlebotomy, UA, rapid strep and flu screening, EKGs, catheterization, administer immunizations, IVs, physicals, hearing and vision screening.