Hope Sprague
Tempe,AZ
Summary
Results-driven Clinical Reviewer with expertise in utilization management and compliance. Skilled in conducting thorough patient assessments and ensuring adherence to medical necessity guidelines. Committed to optimizing patient care services and improving overall quality.
Overview
11
11
years of professional experience
1
1
Certification
Work History
RN initial Clinical Reviewer
Blue Cross Blue shield of Arizona
, AZ
08.2017 - Current
- Conducted comprehensive reviews of patient care plans for medical necessity.
- Provided guidance on resource allocation for patient care services.
- Maintained accurate records of reviews and communicated findings effectively.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Performed discharge planning including referrals for post-acute care services when appropriate.
- Referred cases to secondary review for failure to meet criteria.
- Ensured compliance with federal, state, and accreditation requirements related to utilization management.
Quality Review Examiner
United Heathcare/Tricare
Phoenix, Arizona
08.2014 - 08.2017
- Conducted comprehensive patient assessments to identify quality issues.
- Monitored clinical procedures to ensure adherence to established guidelines.
- Facilitated root cause analysis meetings for incident investigations in healthcare settings.
- Provided ongoing support during audits and inspections to maintain quality standards.
- Evaluated performance improvement plans designed by medical staff members aimed at increasing compliance with existing standards.
- Conducted comprehensive assessments of patient care to ensure quality standards were being met.
- Investigated complaints from patients or their families regarding perceived lapses in quality of care received.
- Monitored patient outcomes and developed strategies for improving processes and services based on findings.
Education
Bachelor of Science - Nursing
Clarion University of Pennsylvania
Clarion, PA05-1993
Associate of Science - Nursing
Mississippi Gulf Coast Community College
Gautier, MS05-1980
LPN -
Jamestown School of Practical Nursing
Jamestown NY06-1974
Skills
- Comprehensive assessments
- Patient care planning
- Utilization review
- Quality improvement
- Discharge planning
- Patient outcomes monitoring
- Medical necessity assessment
- Utilization management
- Data analysis
- Effective communication
- Critical thinking
- Problem solving
- Attention to detail
- Insurance verification
- Clinical assessment
- Medicare
- HIPAA compliance
Certification
RN State of Arizona 2001
Timeline
RN initial Clinical Reviewer
Blue Cross Blue shield of Arizona
08.2017 - Current
Quality Review Examiner
United Heathcare/Tricare
08.2014 - 08.2017
Bachelor of Science - Nursing
Clarion University of Pennsylvania
Associate of Science - Nursing
Mississippi Gulf Coast Community College
LPN -
Jamestown School of Practical Nursing