Irene Waddington
Henderson,NV
Summary
Utilization Review Nurse and Care Management with a proven track record in hospital and insurance, adept at ensuring cost-effective patient care through meticulous utilization review processes. Skilled in collaboration and maintaining up-to-date clinical knowledge, complemented by expertise in Cyber Security fundamentals. Demonstrates exceptional analytical and interpersonal skills, significantly enhancing patient outcomes and service efficiency.
Overview
9
9
years of professional experience
Work History
Utilization Review Nurse
Prominence Health Plan
Reno, NV
11.2021 - 06.2023
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Referred cases to secondary review for failure to meet MCG criteria.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
Utilization Management Nurse
ERP International LLC
Las Vegas, NV
05.2019 - 07.2021
- Collaborated with medical management/ physicians, case managers, discharge planner, social worker group meetings to identify issues and find cost-effective solutions.
- Kept detailed documentation on all utilization reviews by using Interqual medical necessity tool and Genesis/ Cerner software.
- Reviewed patient admissions to determine medical necessity as directed by Interqual and clinical criteria.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Contacted insurance carriers to obtain authorizations for services delivered to patients.
- Collaborated with interdisciplinary team of professionals as well as patients and families to determine appropriate treatment optionsin supporting discharge planning.
- Gathered community resources and coordinated referrals to obtain services.
Utilization Management Nurse
Total Med Staffing, Silver Summit
Las Vegas, NV
10.2018 - 04.2019
- Collaborated with case managers and medical directorin group meetings to identify issues and find cost-effective solutions.
- Kept detailed documentation on all utilization reviews by using Interqul software and Centene software.
- Referred cases to secondary review for failure to meet Inpatient Acute criteria.
- Reviewed patient admissions to determine medical necessity as directed by Interqual and clinical criteria.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Managed letters, reconsideration and first level appeal processes pertaining to denials and potential denials as outlined by insurance carriers.
Utilization Management Nurse
Anthem Blue Cross Blue Shield
Las Vegas, NV
03.2016 - 08.2018
- Collaborated with Medical Director, community mental health providers, and case managers in group meetings to identify issues and find cost-effective solutions.
- Kept detailed documentation on all utilization reviews by using .
- Referred cases to secondary review for failure to meet Milliman and Robertson criteria.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations, as well as clinical case presentations .
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Monitored and recorded patient condition, their psychiatic conditions, recovery progress and medication side effects.
Care Manager
Value Options/Beacon Health Care Options
Las Vegas, NV
06.2014 - 11.2015
- Advocated for members and families, with mental health and medical diagnosis, to coordinate care and navigate resources within Medicaid system.
- Determined functional status, activity, acuity and self-management levels to make proper care referrals.
- Cooperated with local service providers, outreach workers, case managers and collaborative agencies to facilitate services for members.
- Protected patient data in alignment with HIPAA privacy protocols.
- Constructed case notes and comprehensive reports, including data entry into McKesson portal.
- Participated in case conferences with multi-disciplinary team to discuss client care planning and progression.
Care Manager
Beacon Health Options (Value Options)
Las Vegas, NV
05.2014 - 11.2015
- Collaborated with various healthcare providers to facilitate delivery of services.
- Lowered costs while improving care quality by coordinating services and collaborating with dedicated healthcare team.
- Optimized program resource utilization to prevent unnecessary hospital admissions.
- Coordinated support services and optimized communication between healthcare workers and patients.
- Developed appropriate care plans for at-risk individuals and high-risk families. I worked on a program called Health Care Guidance Program, enrolling patients, and supporting them on phone and in person to get medical and mental health needs met. Visited a few of our patients when they were hospitalized on Boulder City Hospital Psychiatric Unit.
Education
Cybersecurity Professional Bootcamp Program - Cybersecurity
University of Nevada
Las Vegas, NVMaster of Science - Psychiatric Mental Health Nursing
University Of Michigan - Ann Arbor
Ann Arbor, MIBachelor of Science - Nursing
Wayne State University
Detroit, MISkills
- Utilization management RN experienced in commercial, Medicaid/Medicare, VA, and active duty program coordination
- Proven record in reviews of medical, behavioral health, and chemical dependency cases in all levels of care
- Excellent skills in provider relations and utilizing in-network services
Timeline
Utilization Review Nurse
Prominence Health Plan
11.2021 - 06.2023
Utilization Management Nurse
ERP International LLC
05.2019 - 07.2021
Utilization Management Nurse
Total Med Staffing, Silver Summit
10.2018 - 04.2019
Utilization Management Nurse
Anthem Blue Cross Blue Shield
03.2016 - 08.2018
Care Manager
Value Options/Beacon Health Care Options
06.2014 - 11.2015
Care Manager
Beacon Health Options (Value Options)
05.2014 - 11.2015
Master of Science - Psychiatric Mental Health Nursing
University Of Michigan - Ann Arbor
Bachelor of Science - Nursing
Wayne State University
Cybersecurity Professional Bootcamp Program - Cybersecurity
University of Nevada
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