Darena Sparks
Enid,OK
Summary
Dynamic Utilization Review Nurse with over 20 years of nursing experience, specializing in clinical assessments and meticulous record oversight. Proven expertise in delivering comprehensive clinical reviews under high-pressure conditions, ensuring optimal resource utilization and patient care. Strong commitment to enhancing team performance through thorough analysis and effective problem-solving, leveraging extensive knowledge in Utilization Review and Prior Authorization. Consistently recognized for ensuring compliance with healthcare regulations while driving improvements in patient outcomes.
Overview
13
13
years of professional experience
Work History
RN CASE MANAGER
United Healthcare
03.2020 - Current
- Coordinated discharge plan of care with physician, healthcare team, patients, and families to ensure comprehensive post-discharge support.
- Addressed patient inquiries and concerns to deliver quality service and achieve performance benchmarks.
- Documented symptoms, complaints and issues discussed during calls and actions taken in patient medical records.
- Delivered telephone advice based on established guidelines and protocols.
- Referred client or family to appropriate community resources to obtain support for mental or physical illness.
- Delivered health-related advice over the phone to guide patient decisions according to established guidelines and protocols.
RN UTILIZATION REVIEW CASE MANAGER
Ardent Health
03.2018 - 03.2020
- Evaluated medical necessity and cost-effectiveness of services during utilization review processes, ensuring appropriate care delivery.
- Utilized medical criteria and clinical judgment to assess medical cases, leading to informed determinations.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Referred cases to secondary review for failure to meet Interqual inpatient criteria.
- Contacted insurance carriers to obtain authorizations for services delivered to patients.
- Maintained comprehensive documentation on utilization reviews using Interqual and Epic to support audit readiness and compliance.
TELEPHONIC NURSE CASE MANAGER
Humana
05.2016 - 02.2018
- Conducted comprehensive assessments to develop individualized care plans for members.
- Coordinated telephonic outreach to ensure adherence to treatment protocols.
- Collaborated with healthcare providers to facilitate seamless transitions of care.
- Educated clients on available options, enabling informed decision-making.
- Guided clients in developing skills and strategies to effectively address personal challenges.
RN UTILIZATION REVIEW CASE MANAGER/DISCHARGE PLANNER
Saint Francis Hospital
01.2014 - 04.2016
- Coordinated and updated discharge plans with physician, healthcare team, patients, and families to facilitate smooth transitions and continuity of care.
- Assessed patients for discharge planning and integrated home care, home infusion, and durable medical equipment (DME) services to ensure comprehensive care.
- Collaborated with interdisciplinary teams to develop and implement individualized care plans.
Education
Associate of Science - Nursing
Northern Oklahoma College
Enid, OKSkills
- Utilization management
- Discharge coordination
- Patient evaluation
- Chronic care management
- HIPAA regulations
Timeline
RN CASE MANAGER
United Healthcare
03.2020 - Current
RN UTILIZATION REVIEW CASE MANAGER
Ardent Health
03.2018 - 03.2020
TELEPHONIC NURSE CASE MANAGER
Humana
05.2016 - 02.2018
RN UTILIZATION REVIEW CASE MANAGER/DISCHARGE PLANNER
Saint Francis Hospital
01.2014 - 04.2016
Associate of Science - Nursing
Northern Oklahoma College
NOC Spirit of Nursing award per instructors
Voted the Spirit of Nursing award per faculty.