Donna Adam
Spring Branch
Summary
Seasoned Utilization Review Nurse with a proven ability to enhance patient care through strategic utilization management and comprehensive clinical assessment. Recognized for excellence in collaborative teamwork, ensuring adherence to healthcare regulations while consistently achieving optimal patient outcomes. Extensive experience in developing detailed care plans and coordinating patient care across various healthcare settings, including inpatient, observation, and outpatient environments. Committed to delivering exceptional healthcare services, backed by a solid foundation in Medicare knowledge and proficiency in Microsoft Office. Actively seeking remote opportunities in Behavioral Health while remaining open to other medical roles.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Utilization Review Registered Nurse
TRIWEST Healthcare Alliance, Pacer Staffing
04.2025 - 08.2025
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Devise or identify solutions for irregular requests and issues.
- Supervised and maintained all utilization review documentation through InterQual.
- Performed admission reviews based for medical necessity based upon InterQual and Defense Health agency specification.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Recorded details regarding therapies to keep patient charts updated.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
- Performed admission reviews based for medical necessity based upon Defense Heath Agency .
Utilization Review Nurse , Telephonic
ICOMA {agency for Aetna Position}
06.2024 - 02.2025
- Conducted thorough evaluations of medical necessity for procedures, leading to optimal resource utilization.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Facilitated compliance with federal and state regulations, maintaining high standards of healthcare delivery.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Devise or identify solutions for irregular requests and issues.
- Supervised and maintained all utilization review documentation through Milliman Criteria
- Performed admission reviews based for medical necessity based upon Milliman Criteria specification.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Managed patients recovering from medical or surgical procedures.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization and concurrent review of services requiring notification.
- Recorded details regarding therapies to keep patient charts updated.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
RETRO REVIEW NURSE 2 REMOTE
Humana
11.2021 - 04.2024
- Performed medical necessity reviews on retrospective cases, to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefits
- Maintained a thorough understanding of the provider and member centric focus, authorization requirements and clinical criteria including MCG care guidelines and Humana's internal criteria, and National and Local coverage guidelines
- Maintained an understanding of accreditation and regulatory requirements, and ensured these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
- Collaborated with healthcare team for coordinated patient care.
- Work From Home
- Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
- Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
PRIOR-AUTH REVIEW NURSE 2 REMOTE
Humana
11.2019 - 11.2021
- Performed approximately 10 medical necessity reviews per day for inpatient and outpatient prior authorization requests to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefits
- Consulted with Medical Directors when care does not meet applicable criteria or medical policies
- Identified Clinical Program opportunities and refers members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs)
- Collaborated, educated, and consulted with Providers, Product, Implementation, Compliance, and Health Plans to ensure consistent application of clinical criteria as well as promote to optimal patient outcome
- Work From Home
- Investigated and resolved issues affecting hospital operations and patient care.
- Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
- Recorded details regarding therapies to keep patient charts updated.
- Evaluated patient histories, complaints, and current symptoms.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
HOME HEALTH REVIEW NURSE 2 REMOTE
Humana
06.2016 - 11.2019
- Established immediate and long-term therapeutic goals, in setting priorities, and in developing patient Plan of Care (POC).
- Coordinated with doctors and specialists to ensure comprehensive patient care.
- Advocated for patient needs, ensuring personalized attention and appropriate care.
- Advised patients and caregivers of proper wound management, discharge plan objectives, safe medication use, and disease management.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Performed admission reviews based for medical necessity based upon Medicare Advantage HMO, PPO, PFFS and CMS specifications.
- Supervised and maintained all utilization review documentation through Humana platform.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Performed admission reviews based for medical necessity based upon Medicare Advantage HMO, PPO and PFFS specification.
- Educated family members and caregivers on patient care instructions.
- Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
- Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
- Evaluated patient histories, complaints, and current symptoms.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Managed patients recovering from medical or surgical procedures.
- Implemented care plans for patient treatment after assessing physician medical regimens.
- Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
CASE MANAGEMENT REMOTE
Humana
01.2015 - 06.2016
- Managed a caseload of diverse clients, successfully addressing their unique needs while maintaining high standards of service delivery.
- Maintained accurate records and documentation, ensuring compliance with regulatory requirements and facilitating seamless audits.
- Facilitated timely transitions between care settings by coordinating with healthcare providers, families, and insurance companies.
- Created well-written, effective care plans appropriately matching needs of clients following standards and guidelines of funders, contractors and governmental regulations.
- Participated in team projects, demonstrating an ability to work collaboratively and effectively.
- Self-motivated, with a strong sense of personal responsibility.
- Adaptable and proficient in learning new concepts quickly and efficiently.
- Proved successful working within tight deadlines and a fast-paced environment.
- Versatile professional with strong problem-solving skills and history of adapting to diverse challenges. Applies innovative solutions and technical expertise to deliver exceptional results. Committed to streamlining processes and advancing organizational objectives.
- Organized and detail-oriented with a strong work ethic.
- Managed time efficiently in order to complete all tasks within deadlines.
- Proven ability to learn quickly and adapt to new situations.
- Learned and adapted quickly to new technology and software applications.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Identified issues, analyzed information and provided solutions to problems.
- Demonstrated strong organizational and time management skills while managing multiple projects.
- Cultivated interpersonal skills by building positive relationships with others.
- Worked effectively in fast-paced environments.
TRANSITION CASE MANAGEMENT REMOTE
Humana
11.2010 - 01.2015
- Conducted transitions of care management for Medicare patient population, including hospital, OBS, and post-acute care follow ups.
- Initiated care planning and subsequent action steps for members, coordinating with interdisciplinary team
- Assessed patient's family and caregiver system.
- Served as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems
- Referred patient to necessary services and support to include assistance with transportation, food insecurity, navigation of and application for benefits including, working to reduce costs associated with prescription medications
- Applied effective time management techniques to meet tight deadlines.
- Organized professional with expertise in managing resources and optimizing performance. Proficient in providing valuable insights and supporting decision-making processes. Committed to enhancing productivity and contributing to overall success.
- Goal-oriented professional with proven success in applying analytical skills to solve complex problems and overcome challenges. Dedicated to enhancing team performance and driving business success.
- Worked well in a team setting, providing support and guidance.
- Passionate about learning and committed to continual improvement.
- Participated in team projects, demonstrating an ability to work collaboratively and effectively.
- Self-motivated, with a strong sense of personal responsibility.
- Identified issues, analyzed information and provided solutions to problems.
- Organized and detail-oriented with a strong work ethic.
CLINICAL ADVISOR
Humana
08.2007 - 11.2010
- Performed medical necessity reviews for Acute, LTAC, SNF, and home health settings. Medical necessity reviews for out of network treatments.
- Preformed DME reviews to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefits
- Consulted with Medical Directors when care does not meet applicable criteria or medical policies
- Documented clinical information completely, accurately, and in a timely manner
- Maintained a thorough understanding of the provider and member centric focus, authorization requirements and clinical criteria including MCG care guidelines and Humana internal criteria, and National and Local coverage guidelines
- Identified Clinical Program opportunities and refers members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs)
- Collaborated, educated, and consulted with Providers, on Implementation, Compliance, and Health Plans to ensure consistent application of clinical criteria as well as promote to optimal patient outcome
- Maintained a thorough understanding of accreditation and regulatory requirements, and ensured these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
- Performed other duties as assigned
- Worked through established contract resource organizations and with sponsor and networks.
- Collaborated with other healthcare professionals to develop comprehensive care plans.
- Educated patients on preventive healthcare strategies and at-home care.
- Maintained detailed records of patient health information in Humana Platform.
- Assessed patient history to identify concerning symptoms, diagnose concerns and develop tailored treatment plans.
Home Health Nurse
Various Agencies
08.2001 - 08.2007
- Developed strong rapport with patients and families, fostering trust and open communication during challenging times.
- Educated patients and families on disease management, medication safety, and at-home healthcare strategies to promote selfcare.
- Contributed to the overall success of the home health agency by maintaining high levels of patient satisfaction and positive outcomes.
- Trained, guided, supported and supervised home health aide care providers.
- Performed skilled nursing procedures such as IV insertion, catheterization, blood draw, tracheostomy care efficiently while maintaining strict infection control measures.
- Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
- Provided physical assessments, medication, and chronic disease management to home health patients.
- Administered different therapies and medications in line with physician orders and treatment plan.
- Educated patients and families on disease processes, medications and treatments.
- Administered medications and treatments as prescribed by physicians.
- Coordinated with other healthcare team members to support patient needs.
- Assessed patients' health status and developed individualized care plans to suit needs.
- Collaborated with vendors to procure medical equipment, supplies and services.
- Monitored vital signs, developed and implemented care plans, and documented patient progress.
- Provided emotional support and kind companionship to patients and families to increase overall wellness.
- Monitored patient reactions after administering medications and IV therapies.
- Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
- Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
- Recorded details regarding therapies to keep patient charts updated.
- Implemented care plans for patient treatment after assessing physician medical regimens.
- Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
RN Floor Nurse
Christus Santa Rosa Hospital
06.1997 - 08.2001
- Floated to the following floors: Tele, med-surge, recovery, MICU, CCU, Long term care
- Provided comprehensive assessments and care for patients in a fast-paced acute care setting.
- Collaborated with physicians and healthcare teams to develop and implement individualized care plans.
- Administered medications and treatments while monitoring patient responses and adjusting care as needed.
- Educated patients and families on health management and post-discharge care to ensure continuity of care.
- Maintained accurate and detailed patient records in compliance with healthcare regulations
- Administered basic patient care and treatments by dressing wounds, treating bedsores, giving enemas and performing catheterizations.
- Established compassionate environment by providing psychological, emotional and spiritual support to patients and families.
Education
Bachelor of Science - BEHAVIORAL HEALTH AND SCIENCES, B.S
UNIVERSITY OF HOUSTON
Victoria, TX05.1989
Associate of Science - Registered Nurse
VICTORIA JUNIOR COLLEGE
Victoria, TX05.1989
Skills
- MCG criteria analysis
- Proficient in InterQual
- Knowledge of ASAM criteria guidelines
- Skilled in conducting evaluations in medical and behavioral health
- Client support and advocacy
- Healthcare compliance knowledge
- Effective healthcare service coordination
- Expertise in Utilization Management, Pre-authorization management, Retro Utilization Management, Case Management, Home health care for Medial and behavioral health inpatient and outpatient settings
- Experience in palliative care
- Patient discharge management
- Knowledge of healthcare regulations and adherence
- Strategic resource management
- Insurance eligibility verification
- Development of patient care plans
- Microsoft Office and Microsoft Excel Proficiency
Certification
- Texas Compact RN License Credential ID 554682 Expires Jan 2027
- Certified Case Manager Expires May 2028
Timeline
Utilization Review Registered Nurse
TRIWEST Healthcare Alliance, Pacer Staffing
04.2025 - 08.2025
Utilization Review Nurse , Telephonic
ICOMA {agency for Aetna Position}
06.2024 - 02.2025
RETRO REVIEW NURSE 2 REMOTE
Humana
11.2021 - 04.2024
PRIOR-AUTH REVIEW NURSE 2 REMOTE
Humana
11.2019 - 11.2021
HOME HEALTH REVIEW NURSE 2 REMOTE
Humana
06.2016 - 11.2019
CASE MANAGEMENT REMOTE
Humana
01.2015 - 06.2016
TRANSITION CASE MANAGEMENT REMOTE
Humana
11.2010 - 01.2015
CLINICAL ADVISOR
Humana
08.2007 - 11.2010
Home Health Nurse
Various Agencies
08.2001 - 08.2007
RN Floor Nurse
Christus Santa Rosa Hospital
06.1997 - 08.2001
Associate of Science - Registered Nurse
VICTORIA JUNIOR COLLEGE
Bachelor of Science - BEHAVIORAL HEALTH AND SCIENCES, B.S
UNIVERSITY OF HOUSTON