Diane Stewart
Registered Nurse
Tallahassee,Florida
Summary
Dynamic Utilization Review Nurse at Centene, recognized for enhancing patient care quality and reducing healthcare costs through effective resource management and regulatory compliance. Expert in evidence-based practices and patient advocacy, facilitating interdisciplinary collaboration and optimizing care coordination. Committed to continuous learning and improving documentation techniques to streamline case management processes.
Overview
7
7
years of professional experience
Work History
Utilization Review Nurse
Centene
10.2017 - Current
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
- Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
- Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
- Increased staff efficiency by providing ongoing education on proper documentation techniques necessary for accurate claims processing.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
- Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
- Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
- Led interdisciplinary team meetings to discuss complex cases, facilitating comprehensive care planning.
- Promoted patient education by providing resources and information on treatment options and healthcare rights.
- Increased patient satisfaction by advocating for necessary patient care and services.
- Ensured timely patient discharges by coordinating with healthcare teams, optimizing bed availability.
Education
Associate of Science - Nursing
Valencia College
Orlando, FL09-1978
Skills
- Utilization review
- Regulatory compliance
- Evidence-based practice
- Care coordination
- Case management
- Patient advocacy
- Clinical documentation
- Interdisciplinary collaboration
- Patient education
Timeline
Utilization Review Nurse
Centene
10.2017 - Current
Associate of Science - Nursing
Valencia College
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