Daphne Davis
Hazard,KY
Summary
- Experienced and reliable Utilization Review Nurse/Case manager for multiple departments including ED, ICU/CCU, Telemetry, Med-Surg, OBS Unit, Pediatrics, Maternal/Infant.
- Knowledgeable in admissions and stay reviews.
- Hardworking and proactive.
- Recognized consistently for performance excellence.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Utilization Management Coordinator/Case Manager
Hazard ARH Medical Center
Hazard, KY
01.2007 - Current
- Conduct admission reviews, concurrent reviews and retrospective reviews around 25 - 70 per day. Report avoidable delays based on medical records review.
- Perform admission reviews based on medical necessity utilizing McKesson InterQual criteria.
- Identify inappropriate utilization of services/settings through application of established clinical criteria using InterQual and CMS guidelines for medical necessity.
- Perform prior authorization review of services requiring notification.
- Completed initial assessments of patients and family to determine and address individual home care needs.
- Facilitated daily unit board meetings with interdisciplinary team such as physicians, pharmacist, social worker and other case managers to find effective solutions to members' issues.
- Perform ongoing assessments to evaluate member's needs, working with multidisciplinary team to develop, initiate, manage and modify individualized plans of care.
- Evaluate medical guidelines and benefit coverage to determine appropriateness of services within the scope of the plan.
- Add and replace ICD/CPT codes to make sure patient's are being billed correctly.
- Proactively speak with ED doctors, providers and hospitalists to obtain the appropriate status order.
- Discuss with physician advisor if review criteria are not met, or if when met, there is concern about level of care based on complexities of patient's conditions or questions about quality of care.
- Communicate with payers in regards to clinical information to ensure support of medical necessity/ level of care to successfully avoid or reverse denials.
- Utilize critical thinking skills and work in a fast paced environment with minimal supervision.
- Maintain accurate records of all members, adhere to the company policy in safeguarding HIPPA and release of Patient health information PHI.
- Train new staff and act as a mentor, providing resources and communicate company goals. In addition, inspire and motivate staff.
- Assisted with the development of a rural hospital to home project in collaboration with Harvard University. This consisted of training staff in case management/UR and participating in a simulated situation.
Documentation Improvement Specialist
Hazard ARH Medical Center
Hazard, KY
02.2001 - 01.2007
- Evaluate the quality of the medical record system to determine the service is in compliance with state and federal regulations and medical record standards.
- Provide consultation and education to physicians concerning clinical documentation requirements and advise them on the impact upon medical records services and actions required for implementation and compliance.
- Consult with facility administrators and their medical record staff to provide them with interpretations of State and Federal regulations; to advise on appropriate corrective measures for compliance.
- Review patients’ records to ascertain if appropriate type and quality of care was given according to established criteria for the diagnosis.
- Perform retrospective chart review of patients who have a change of status to assure that necessary payment is changed.
- Assisted in developing and implementing a data management software to track the financial success/ outcome of CDI program.
Staff Nurse, Mother-Baby Unit
Hazard ARH Medical Center
Hazard, KY
07.1993 - 02.2001
- Provided Assessment of pregnant women, post-partum women and babies.
- Worked closely with the obstetricians and department staff.
- Assist during labor and delivery.
- Provided post-partum care and patient assessment.
- Performed Finnegan Score assessments on newborns for NAS.
- Performed well baby and sick baby assessments and care.
- Worked closely with social services in cases of NAS · Referred mothers and babies to community resources such as: First Steps, Lambs Ministry, local health departments and breast feeding groups.
Education
Bachelor of Science - Nursing
Morehead State University
Morehead, KY05.1993
Skills
- Proficient in InterQual screening tool
- BSN with over 29 years of experience working at a acute inpatient setting
- Patient and family advocacy
- Strong clinical judgment
- MEDITECH EMR / EHR
- Discharge planning coordination
- Physician consultations
- Training and mentoring
- Willingness to learn
- Excellent team player
Certification
- InterQual Certified Instructor
- Registered Nurse : State of Kentucky; License Number 1074051
References
Marcus Pigman
Kentucky Office of Rural Health. - Project Manager
606-439-3557 Ext. 83583
Johnnie Lovins - RN
HCTC - Nursing Instructor
606-216-0644
Tammy Cornett - RN
Wellcare - Transitional Care Coordinator
606-309-6318
Timeline
Utilization Management Coordinator/Case Manager
Hazard ARH Medical Center
01.2007 - Current
Documentation Improvement Specialist
Hazard ARH Medical Center
02.2001 - 01.2007
Staff Nurse, Mother-Baby Unit
Hazard ARH Medical Center
07.1993 - 02.2001
Bachelor of Science - Nursing
Morehead State University
- InterQual Certified Instructor
- Registered Nurse : State of Kentucky; License Number 1074051
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