Donnita Alligood

Core Competencies

• InterQual Criteria Application
• Concurrent, Retrospective & Pre-Cert Reviews
• Medical Necessity Determination
• Level-of-Care Assessment (IP/OBS/OP)
• Denial Prevention & Appeals Support
• CMS & Payer Regulatory Compliance
• Clinical Documentation Review
• LOS & Utilization Metrics Monitoring
• EMR systems and prior authorization platforms
• Microsoft Office Suite (Word, Excel, Outlook)

• Delivered high-quality patient care in a fast-paced clinical environment.
• Interpreted labs, imaging, and physician documentation to support care planning utilizing Epic Systems EHR.
• Collaborated with interdisciplinary teams to coordinate safe, efficient patient care.
• Ensured accurate, timely documentation aligned with regulatory and organizational standards.

• Case-managed orthopedic and cardiac patients enrolled in the Medicare Bundled Payments for Care Improvement (BPCI) program, conducting telephonic risk assessments and delivering comprehensive perioperative patient education.
• Coordinated post-acute services, including home health and physical rehabilitation, to support compliant transitions of care, reduce unnecessary readmissions, and optimize Medicare benefit utilization.

• Performed care coordination and discharge planning for neonatal, pediatric, cardiac, surgical, and medical-surgical patients.
• Completed prior authorizations for medically necessary services and durable medical equipment.
• Coordinated fixed-wing flight ambulance transfers to medical facilities for specialized high-acuity level of care.

• Provided in-home assessments, medication reconciliation, disease-specific education, extensive wound care, IV infusion as directed by physician orders, and referrals to community resources.
• Prepared and completed time-sensitive Medicare documentation on all patients, including case conferences, patient contacts, medication management, and patient-centered care plan development.

• Completed acute/inpatient prospective payment utilization review for medical necessity utilizing MCG 21+ed. clinical criteria and Medicare guidelines.
• Negotiated an appropriate level of care setting.
• Referred clients to case management as medical condition warranted or other underutilized services.
• Adhered to accreditation, contractual, and regulatory turnaround times in all review processes.

• Conducted clinical assessments for identification and enrollment of elevated risk, special needs, Medicare Advantage members eligible for chronic disease value-based care management program.
• Developed individualized patient-centered care plans.
• Provided evidence-based interventions to empower patients to manage their chronic conditions.
• Utilized motivational interviewing skills to engage the member and facilitate behavior change.
• Educated and promoted member utilization of value-based programs to promote member wellness.

• Identified and educated on the appropriate utilization of health plan services and benefits for the Medicaid line of business.
• Responsible for telephonic case management and comprehensive patient education for health optimization and prevention of readmission.
• Performed environmental lead case management for pediatric beneficiaries.