ELAINE CRAWFORD
Beachwood,NJ
Summary
Dedicated Utilization Review Nurse with 20 years of case management experience, including at HMH/Riverview Medical Center. Expert in clinical assessment and records analysis, ensuring optimal patient care and resource utilization. Proven ability to enhance documentation and reporting processes, contributing to improved healthcare outcomes and operational efficiency. I have good customer service skills and enjoy helping not only my clients but also my peers.
I consider myself "well-rounded" with regard to travel. As a child I lived in Africa, England, and then Australia in my teen years.
Overview
20
20
years of professional experience
Work History
Utilization Review Nurse
HMH/Ocean University Medical Center
09.2014 - 04.2025
- Conducted comprehensive reviews of patient cases to determine medical necessity and appropriateness of care.
- Collaborated with healthcare providers to ensure adherence to best practices and regulatory requirements.
- Utilized electronic health records to document findings and facilitate effective communication among team members.
- Monitored ongoing treatment plans, recommending adjustments based on evolving patient needs and clinical guidelines.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
Utilization Review Nurse
HMH/Riverview Medical Center
04.2005 - 09.2013
- Conducted comprehensive reviews of patient cases to determine medical necessity and appropriateness of care.
- Collaborated with healthcare providers to ensure adherence to best practices and regulatory requirements.
- Utilized electronic health records to document findings and facilitate effective communication among team members.
- Analyzed clinical data to identify trends, supporting quality improvement initiatives within the department.
- Monitored ongoing treatment plans, recommending adjustments based on evolving patient needs and clinical guidelines.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Mitigated potential legal issues related to improper admission or discharge decisions by consulting with physicians regarding complex cases that required further clarification.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
- Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
- Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
- Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
- Enhanced patient satisfaction by collaborating with interdisciplinary teams to develop individualized care plans, ensuring appropriate level of care.
- Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
- Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient's unique circumstances.
- Performed admission reviews based for medical necessity based upon Milliman specification.
- Reduced unnecessary medical costs, ensuring treatments met established medical guidelines and policies.
Education
Associate In Science Degree - Nursing
Union County College
Cranford, NJ12.1991
Skills
- Clinical assessment
- My clinical experience prior to case management and UR was ED nursing
- Interpersonal and written communication
- Prior authorization
- HIPAA compliance
- Physician consultations
- Insurance verification
- Healthcare regulations
- Milliman guidelines
- Teamwork
- Problem-solving
- Time management
- Attention to detail
- Compassionate and caring
- Organizational skills
- Accurate documentation
Timeline
Utilization Review Nurse
HMH/Ocean University Medical Center
09.2014 - 04.2025
Utilization Review Nurse
HMH/Riverview Medical Center
04.2005 - 09.2013
Associate In Science Degree - Nursing
Union County College
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