James Hughes

Utilization Review Nurse

CarePlus Health Plans

Miami, FL

02.2003 - 01.2024

Assessed patient medical records to determine the appropriateness of requested services and procedures.
Determined medical necessity and cost-effectiveness of services through utilization review processes.
Served as a resource for staff members seeking guidance on utilization review matters.
Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
Contacted insurance carriers to obtain authorizations for services delivered to patients.
Facilitated communication between payers, providers and patients concerning authorization issues or concerns.
Developed case management plans based on individual patient needs and eligibility criteria.
Communicated with external partners such as managed care organizations or vendors on a regular basis.
Performed discharge planning including referrals for post-acute care services when appropriate.
Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.