Compassionate and detail-oriented Registered Nurse with over 16 years of clinical experience, including a strong background in Labor and Delivery and current expertise in Utilization Management. Adept at conducting comprehensive medical necessity reviews, applying MCG guidelines, and collaborating with multidisciplinary teams to ensure quality, cost-effective care. Skilled in clinical documentation review and regulatory compliance. Brings a patient-centered mindset from the bedside care into the managed care environment, with a strong commitment to evidence-based decision making and healthcare quality improvement.
- Conduct comprehensive clinical reviews of medical records to determine medical necessity, appropriateness, and efficiency of healthcare services based on established guidelines and evidence based criteria (e.g. MCG).
-Collaborate with physicians, healthcare providers, and interdisciplinary teams to ensure high-quality while managing healthcare costs.
-Utilize clinical expertise to evaluate inpatient services and concurrent review cases.
-Maintain up-to-date knowledge of health plan policies, regulatory compliance standards and clinical best practices to ensure accurate decision making.