EBONY BROWN
Ohio Department of Medicaid
Oviedo,FL
1
Certification
9
years of professional experience
Registered Nurse with 8+ years of clinical experience, including utilization management, case management, home health, and Medicaid services. Experienced in medical necessity review, prior authorization, regulatory compliance, Medicare and Medicaid guidelines, and interdisciplinary collaboration. Recognized as a preceptor and mentor with a proven ability to support staff development, quality improvement, operational goals, and positive member outcomes. Skilled in provider engagement, auditing, care coordination, and utilization management operations.
Work History
Utilization Management Nurse 2
1 Year- Conduct comprehensive utilization reviews of authorization requests, assessing medical necessity, level of care, and compliance with coverage guidelines, regulatory standards, and organizational policies.
- Interpret and apply CMS, regulatory, and health plan guidelines to ensure accurate utilization management decisions.
- Collaborated with physicians, providers, medical directors, and interdisciplinary teams to resolve complex authorization and care coordination issues, enhancing patient care outcomes.
- Served as preceptor and mentor to newly hired Utilization Management Nurses, delivering onboarding support, workflow training, clinical guidance, and best practice education to ensure seamless integration.
- Provided ongoing coaching and subject matter expertise to team members, fostering consistency in clinical reviews and regulatory compliance for improved authorization decision-making.
RN Case Manager
1 Year 7 Months- Coordinated multidisciplinary care plans to enhance patient outcomes and ensure continuity of care.
- Collaborated with physicians, care teams, and community resources to enable safe transitions of care.
- Monitored compliance with clinical, regulatory, and payer requirements to uphold quality metrics.
Independent Provider
9 Years 2 Months- Managed member services, ensuring Medicaid compliance and adherence to documentation standards.
- Coordinated care among members, caregivers, healthcare providers, and community agencies to enhance support.
- Maintained audit-ready records and assessed care plan effectiveness through ongoing clinical evaluation.
- Additional Nursing Experience: Bridge Home Health & Hospice (Case Management RN), Firelands Regional Medical Center (Medical Surgical RN), Caretenders Home Health (Home Health RN).
Nurse Reviewer - Utilization Review
1 Year 6 Months- Reviewed 60 to 80 prior authorization requests daily to ensure compliance with evidence-based clinical criteria and payer guidelines.
- Performed medical necessity determinations for outpatient and specialty services, consistently meeting productivity standards.
- Analyzed clinical documentation to support consistent utilization decisions and regulatory compliance.
- Collaborated with providers and interdisciplinary teams to gather clinical information, enhancing authorization turnaround times.
Education
Bachelor of Science - Nursing
currently
RN Diploma
Associate in Science
Licensed Practical Nurse
Skills
Utilization Management
Prior Authorization
Medical Necessity Review
Auditing & Compliance
Regulatory Compliance (CMS
NCQA
URAC)
Medicare & Medicaid
MCG & InterQual
Data Analysis & Trend Reporting
Case Management
Provider Collaboration
Process Improvement
Team Leadership
Microsoft Office
SharePoint
Accomplishments
- Manage high-volume workloads while consistently meeting productivity, quality, compliance, and turnaround time expectations.
- Lead training initiatives and provide subject matter expertise on utilization management workflows, regulatory requirements, and medical necessity determinations.
- Collaborated across interdisciplinary teams to resolve barriers to care and improve member experience.
- Supported compliance, documentation accuracy, audit readiness, and adherence to regulatory standards.
- Experienced in provider communication, stakeholder engagement, and operational problem solving.
Certification
Compact Registered Nurse License, Utilization Review 101 Certificate, Heidi's Data Abstraction 101 Certificate
Timeline
Utilization Management Nurse 2
Humana
10.2025 - CurrentRead More
RN Case Manager
AdventHealth
03.2025 - CurrentRead More
Nurse Reviewer - Utilization Review
Elevance Health
05.2023 - 11.2024Read More
Independent Provider
Ohio Department of Medicaid
08.2017 - CurrentRead More
Sandusky Career Center School of Practical Nursing
Licensed Practical Nurse
Read More
Bowling Green State University
Associate in Science
Read More
Sandusky Career Center
RN Diploma
Read More
Pima Medical Institute
Bachelor of Science from Nursing
Read More