Erin Davies
Elyria,OH
Summary
Knowledgeable LPN with robust background in managing prior authorization processes. Adept at streamlining workflows and ensuring compliance with regulatory standards. Demonstrated proficiency in patient advocacy and effective communication with healthcare providers.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Prior Authorization Nurse I
Ambetter Healthcare
02.2022 - 12.2023
- Company Overview: Utilization Management Pre-Service: WA, OH, NH, SC, NV, NJ, NM, & KS - Remote
- Outpatient Prior Authorization Nurse Reviewer:
- Follow the direction of our department manager and team lead
- Conducted thorough reviews of medical records, identifying necessary documentation to support prior authorization requests.
- Promoted a culture of continuous improvement within the Prior Authorization department by regularly reviewing processes and making recommendations for optimization.
- Participated in interdisciplinary team meetings, collaborating with other healthcare professionals to ensure seamless coordination of care for patients requiring prior authorizations.
- Developed strong relationships with insurance representatives, facilitating effective communication and expediting resolution of issues.
- Assisted in maintaining compliance with changing regulations and policies by staying up-to-date on industry trends and best practices.
- Demonstrated commitment to professional development by participating in ongoing training opportunities related to the field of Prior Authorization nursing.
- Worked closely with case managers to facilitate appropriate utilization of healthcare resources through the prior authorization process.
- Maintained detailed records and documentation related to prior authorization requests, ensuring accurate tracking and reporting for both internal and external stakeholders.
- Provided exceptional customer service to both patients and healthcare professionals, addressing concerns related to the prior authorization process.
- Collaborated with healthcare providers to ensure accurate submission of required documentation for timely authorizations.
- Mentored new hires within the team, sharing expertise in navigating complex insurance guidelines and best practices for managing workflow efficiently.
- Streamlined the prior authorization process, reducing wait times and improving overall efficiency.
- Expedited urgent requests for prior authorization, ensuring timely access to critical medical treatments.
Nurse Reviewer
A. Frazier & Associates
12.2018 - 02.2022
- Licensed Practical Nurse Assignments contracted with Centene Corporation
- Home State Health Plan – Missouri: Program Coordinator: helping the OB Care Management Team with outreaches for completing NOP assessments, post discharge assessments, SUD pregnancy assessment for Smart start for pregnancy members, Opiend Substance Misuse Integrated Care Management Assessment, Health risk assessments for behavioral health team, for Medicaid, and Ambetter members
- Contacting and updating members on the Care Management High Priority report
- Contacting providers for care gap outreach
- Creating care coordination Care plans for high-risk members to close care gaps or claims review to monitor health changes
- Julie Mertzluft Manager at Home State Health Plan
Care Manager Consultant
Centene Corporate
10.2019 - 12.2020
- Company Overview: Missouri: Care Manager Consultant
- Working on a pilot program with Home State Health and Centene Corporate to promote well checks, Medication Assisted Therapy, Prenatal Information and references/ plan benefits for use, Substance Use Disorder Assessments for high-risk pregnancy members due to known or previous S.U.D
- Issues
- Creating slide show presentations on various subjects to present to care managers for further knowledge on S.U.D
- And high-risk pregnancy topics
- Missouri: Care Manager Consultant
- Shelby Schroder Manager at Corporate Centene
Outpatient Prior Authorization Nurse Reviewer
Illinicare
07.2019 - 09.2019
- Company Overview: Illinois: Outpatient Prior Authorization Nurse Reviewer
- Outpatient Pain Management reviews using company policies, McKesson Interqual, MD reviews for determination
- Also retrieved medical records faxes and built the authorization shell in our Trucare system to process pain management requests from providers
- Illinois: Outpatient Prior Authorization Nurse Reviewer
- Jessica Wagner Manager at Illinicare
Outpatient Prior Authorization Nurse Reviewer
Trillium Healthcare
12.2018 - 06.2019
- Company Overview: Eugene Oregon: Outpatient Prior Authorization Nurse Reviewer
- Outpatient surgeries, Procedures, Home healthcare, Hospice, Therapies, Chiropractor/Acupuncture, Office Visits, Imaging, Labs, Testing, and Pain Management and Behavioral Health
- Eugene Oregon: Outpatient Prior Authorization Nurse Reviewer
- Catresa Bowie Manager at Trilium
Concurrent Review Nurse/Case Manager I
Buckeye Health Plan
05.2015 - 07.2018
- Company Overview: Fairlawn, Ohio
- Review Medical Records for DME, Pain Management, Medical Supplies, Infusion, Outpatient procedures, and Home Health Prior Authorization requests
- Write reviews for Medical Director reviews as necessary
- Follow Ohio Medicaid and State Guidelines as well as Buckeye Company Policies and Procedures, utilize McKesson Interqual as required
- Document Clinical Reviews and discharge plans regarding member's care
- Build professional relationships with Home Health Agencies, Physician Offices, Hospitals, customer service, assist with other departments at Buckeye for the benefit of the member
- Follow the direction of our department manager and team lead
- Fairlawn, Ohio
Review Coordinator Team Lead
Kepro
11.2014 - 05.2015
- Company Overview: Seven Hills, Ohio
- Manage the daily work flow for the Review Nurses
- Monitoring Call Databases to ensure timeliness of calls and for customer service purposes
- Act as a liaison between Review Supervisor and Review Nurses
- Provides educational in-services to employees
- Helps with the interview process for potential candidates for the Review Department
- Works on projects delegated by the Review Supervisor
- Train new employees with the review processes and databases
- Responsible for all employees on my assigned weekend
- Help facilities, beneficiaries, and managed care plans with questions, complaints, or issues
- Seven Hills, Ohio
Review Coordinator
Kepro
04.2012 - 11.2014
- Company Overview: Seven Hills, Ohio
- Reviewing medical records to send to physicians for review
- Communicating with beneficiaries, facilities, physicians, and managed care plans on a daily basis regarding appeals
- Working with other departments to help import or purge records into CRIS System
- Trained new employees on processes of the Review Department
- Reviewing and redacting Nevada/Utah reviews
- Using McKesson Interqual for Admission and Discharge for hospital reviews and Higher weighted DRG requests
- Converting faxes from Faxbox to PDF’s for review
- Making sure reviews and faxes are all within CMS time frames
- Manager access to e-board while working weekends
- Proofing letters to be sent to Beneficiaries
- Utilizing Microsoft word and excel programs
- Learned higher weighted DRG and Interqual requests from CMS
- Accepting all responsibilities given by Review Supervisors
- Seven Hills, Ohio
Licensed Practical Nurse
Avon Oaks Nursing Home
09.2010 - 06.2012
- Company Overview: Avon, Ohio
- Caring for patients in Long term care, Alzheimer's, Assisted Living, and Skilled rehab units
- Avon, Ohio
Business Office Liaison
Regency Hospital of Cleveland West
01.2007 - 12.2009
- Company Overview: Middleburg Heights, Ohio
- Entering patient charges for billing purposes
- Middleburg Heights, Ohio
Business Office Associate
Royal Manor Health Care
01.2004 - 12.2007
- Company Overview: Middleburg Heights, Ohio
- Medicare, Medicaid, Worker's Compensation, and Managed Care Billing
- Middleburg Heights, Ohio
Education
No Degree - General Studies
Lorain County Community College
Elyria, OhioLake Ridge Academy
North Ridgeville, OhioLicensed Practical Nurse - LPN
EHOVE School of Practical Nursing
Milan, OH07-2010
Skills
- LPN Certification
- IV Certification
- BLS Certification
- HIPAA Compliance
- Clinical Documentation
- Utilization review
- Teamwork and Collaboration
- Medication and IV administration
- Multitasking
- Excellent Communication
- Active Listening
References
- Chelsea Braun, Supervisor at Ambetter Healthcare, 812-318-7762, Crbraun12@outlook.com
- Ron Waddle, Supervisor at Ambetter Healthcare, 601-850-2764, RWADDLE@CENTENE.COM
- Constance Munn, Team Member at Ambetter Healthcare, 601-941-0524, 309 West Maund Ave., Mendenhall, MS, 39114
- Jonathan Berliner, Team Member at Ambetter Healthcare, 253-313-3233, 18013 50th Street NW, Vaughn, WA, 98394
Certification
- Basic Life Support Certification
- OH Driver's License
- Ohio Board of Nursing - Licensed Practical Nurse- Expires 10/26
- PN 141251 - Multistate license
Timeline
Prior Authorization Nurse I
Ambetter Healthcare
02.2022 - 12.2023
Care Manager Consultant
Centene Corporate
10.2019 - 12.2020
Outpatient Prior Authorization Nurse Reviewer
Illinicare
07.2019 - 09.2019
Nurse Reviewer
A. Frazier & Associates
12.2018 - 02.2022
Outpatient Prior Authorization Nurse Reviewer
Trillium Healthcare
12.2018 - 06.2019
Concurrent Review Nurse/Case Manager I
Buckeye Health Plan
05.2015 - 07.2018
Review Coordinator Team Lead
Kepro
11.2014 - 05.2015
Review Coordinator
Kepro
04.2012 - 11.2014
Licensed Practical Nurse
Avon Oaks Nursing Home
09.2010 - 06.2012
Business Office Liaison
Regency Hospital of Cleveland West
01.2007 - 12.2009
Business Office Associate
Royal Manor Health Care
01.2004 - 12.2007
Lake Ridge Academy
No Degree - General Studies
Lorain County Community College
Licensed Practical Nurse - LPN
EHOVE School of Practical Nursing
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