Donna Spigner
Smyrna,GA
Summary
Registered Nurse dedicated to providing exceptional patient care and superior customer service. Extensive professional nursing experience in several hospital environments, acute inpatient care, short-term rehabilitation, and the community. Performed a broad range of professional, compassionate, and holistic nursing care to the pediatric, adult, and geriatric populations including patients with complex medical needs. Expertise in team communication, program support, and physician collaboration.
Overview
16
16
years of professional experience
Work History
Utilization Analyst
Emory Healthcare Midtown Hospital
05.2023 - Current
- Maintained up-to-date knowledge of payer-specific guidelines to ensure accurate authorizations for medically necessary services.
- Participated in quality improvement initiatives to enhance the overall standard of care within the organization.
- Monitoring that the patient is progressing in their plan of care and meet medical necessity for continued stay.
- Applied critical thinking skills to assess complex medical cases and determine appropriate levels of care in accordance with industry benchmarks.
- Performed admission 25-30 reviews based for medical necessity based upon MCG/ InterQual specifications.
- Ensures that the patient's payer has the clinical information with which to authorize an acute hospital stay and the continued stay services to include covered days and associated services.
Utilization Management Nurse (Remote)
WellStar Kennestone Hospital
06.2021 - Current
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Obtained authorizations from multiple insurance carriers for various levels of care from newborn to geriatric patients.
- Performed revenue cycling for post-service reviews.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Performed post authorization review of services requiring notification.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Registered Nurse ( Remote Medical Management II )
Anthem, Inc.
10.2008 - 06.2021
- Assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services
- Appropriateness of treatment setting by utilizing the applicable medical policy and industry standards
- Coordinate care and services through acute care episode and across continuum.
- Consult with peers and physicians regarding clinical decisions.
- Conducts pre-certification, inpatient, retrospective, out of network and
appropriateness of treatment setting reviews to ensure compliance with applicable
criteria, medical policy, and member eligibility, benefits, and contracts - Work collaboratively with interdisciplinary and healthcare team members, both internal and external within organization
- Facilitate patient care through effective utilization.
- Excellent communication skills, both verbal and written
- Self-motivated, with strong sense of personal responsibility.
- Demonstrated strong organizational and time management skills while managing multiple projects.
- Strengthened communication skills through regular interactions with others.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
Registered Nurse (Skilled Nursing Facility)
ManorCare/Promedica
10.2022 - Current
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Proved successful working within tight deadlines and fast-paced environment.
- Managed care from admission to discharge.
- Cultivated interpersonal skills by building positive relationships with others.
- Organized and detail-oriented with strong work ethic.
- Worked effectively in fast-paced environments.
- Proven ability to learn quickly and adapt to new situations.
- Paid attention to detail while completing assignments.
Education
Master of Science - Education
Capella University
Minneapolis, MN01-2024
Bachelor of Science - Nursing
Capella University
Minneapolis, MN01.2023
Associate of Science - Nursing
Excelsior College (Formally Regents College)
Albany, NY08.2006
Diploma - Nursing
Midlands Technical College
West Columbia, SC02.1991
Skills
- Patient and family advocacy
- Adhere to HIPAA
- EMR / EHR
- InterQual criteria
- Obtaining authorizations
- Interpersonal and written communication
- Telephonic nurse
- Nurse reviewer
- Evidence-based nurse
- Medical codes and terminology
- Determine medical necessity
- Revenue cycling
- Aids in case management
Timeline
Utilization Analyst
Emory Healthcare Midtown Hospital
05.2023 - Current
Registered Nurse (Skilled Nursing Facility)
ManorCare/Promedica
10.2022 - Current
Utilization Management Nurse (Remote)
WellStar Kennestone Hospital
06.2021 - Current
Registered Nurse ( Remote Medical Management II )
Anthem, Inc.
10.2008 - 06.2021
Master of Science - Education
Capella University
Bachelor of Science - Nursing
Capella University
Associate of Science - Nursing
Excelsior College (Formally Regents College)
Diploma - Nursing
Midlands Technical College
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