Donna W. Adam

• 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.
• Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
• Facilitated compliance with federal and state regulations, maintaining high standards of healthcare delivery.

• 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 Humana's 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.

• 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

• Conducted assessment and reassessment of patients, including updating of care plans and interpreting patient needs, while adhering to Company, physician, and/or health facility procedures/policies.

• 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.

• 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.

• • 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
• • Refereed 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,