Jeanne Peneueta
Vancouver,WA
Summary
Dynamic RN Program Manager with extensive experience in Care Management and Utilization Review, specializing in denial management and regulatory compliance. Proven track record in developing evidence-based standards and leading multidisciplinary teams. Skilled in InterQual and strong in communication, ensuring optimal patient outcomes and efficient resource utilization. Recognized for thorough documentation and critical thinking in complex cases.
Demonstrates strong analytical, communication, and teamwork skills, with proven ability to quickly adapt to new environments. Eager to contribute to team success and further develop professional skills. Brings positive attitude and commitment to continuous learning and growth.
Overview
30
30
years of professional experience
1
1
Certification
Work History
RN Program Manager Denials & Procedure Specialist
PeaceHealth
08.2022 - 10.2025
- Accountable for the overall management of the Denial Management/Procedural UR program, I worked collaboratively with the Medical Director and Care Management Director.
- Developed, implemented, and monitored evidence-based standards for denial management.
- Monitored contractual and government requirements for the status determination of surgical cases, and worked closely with the Physician Advisor to ensure appropriate status prior to surgery or procedure.
- Collaborated with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status.
- Analyzed and interpreted denial data. Compares outcomes against program goals. Participated in the creation of standards for data collection, feedback, and analysis.
- Ensured program compliance with mandatory regulatory requirements. Utilized the concepts of quality improvement when planning and implementing process change.
- Analyzed recommended and regulatory best practices, and assimilated the knowledge into clinical practice; assessed and communicated potential risks to revenue capture.
- Identified issues and variations in utilization, and escalated them to the appropriate members of the healthcare team. Actively supported measures that promoted the effective use of resources.
- Managed and responded to all concurrent and post-discharge third-party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Facilitated peer-to-peer reviews as appropriate, and created written appeal letters when indicated.
- Internal expert for RN Case Management staff, and others, on documentation and reimbursement requirements. Served as a resource to the health care team for utilization and denial management.
- Participated in the Utilization Review Committee to present medical necessity data and outcomes, and partnered with care management leadership to develop action plans for improvement.
- Oversaw perioperative pre-authorization and patient class order reconciliation process.
- Facilitated and monitored adherence to the Medicare 2-midnight rule and the Medicare inpatient-only procedure list.
RN Case Manager
PeaceHealth Southwest Medical Center
06.2012 - 08.2022
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Applied medical criteria and clinical judgment to researched cases to evaluate and establish determinations.
- Performed admission and concurrent patient reviews to determine medical necessity, as directed by InterQual criteria.
- Communicated and collaborated with medical providers regarding admission status and progression of care.
- Evaluated medical guidelines to determine the appropriateness of services.
- Conducted comprehensive assessments to identify patient needs and develop targeted interventions.
- Collaborated with multidisciplinary teams to optimize patient outcomes and streamline communication.
- Educated patients and families on disease management and community resources available for support.
- Collaborated with the Care Management Physician Advisor to process concurrent and post-discharge insurance denials.
- Maintained strict patient data procedures to comply with HIPAA law, and prevented information breaches.
- Lead Utilization Review RN CM: precepted and mentored new employees, reorganized staff assignments, acted as an expert resource, and supported difficult and complex InterQual reviews.
- Quality review audits of all facets of InterQual reviews completed at PHSW.
Registered Nurse in Emergency Department
PeaceHealth Southwest Medical Center
08.2001 - 06.2012
- Administered emergency interventions in high-pressure situations to stabilize critically ill patients.
- Collaborated with multidisciplinary teams to quickly assess patients and deliver appropriate treatment, while managing rapidly changing patient conditions. Mentored junior nursing staff on best practices in emergency care and trauma management.
- Key team member of trauma and emergency interventions involving serious head injuries, gunshot wounds, and thoracic trauma.
- Key member of the cardiac, neurologic, and surgical emergency resuscitation team.
- Precepted new RNs on proper techniques, care standards, operational procedures, and safety protocols.
- Administered medications, tracked dosages, and documented patient conditions.
- Monitored and recorded the patient's condition, vital signs, recovery progress, and medication side effects.
- Performed blood and blood product transfusions, and intravenous infusions.
- Monitored and managed various treatment and care interventions.
- Updated physicians on patient test results, and assisted in developing care plans.
- Collected lab specimens, ordering, and interpreting diagnostic tests and lab results.
- Held ACLS, TNCC, ENPC and ABLS (Advanced Burn Life Support) Certifications
Registered Nurse in Emergency Department
Kapiolani Medical Center
09.1998 - 08.2001
Registered Nurse in Emergency Department
Kahu Malama Nurses
01.1998 - 08.1998
Registered Nurse in Emergency Department
Southwest Washington Medical Center
12.1995 - 12.1997
Registered Nurse
Oregon Health Sciences University
09.1995 - 03.1997
- Supervised cardiac stress testing for patients in consideration for heart, renal, or liver transplantation.
- Educated patients and families on health management strategies to promote wellness and prevention.
- Conducted comprehensive assessments to identify patient needs and coordinate appropriate interventions.
- Gathered data and outcomes for the supervising physician for published research articles.
Education
Bachelor of Science - Nursing
University of Portland
Portland, Oregon, OR05-1995
Skills
- Denial management
- Utilization review
- Evidence-based standards
- Regulatory compliance
- Skilled in InterQual, Epic, Microsoft Word, Excel, Teams & Power Point
- Staff Development and Precepting
- Detailed Oriented
- Strong Communication and collaboration skills
- Thorough & accurate documentation and assessments
- Time Management
- Excellent critical thinking and assessment skills
- Highly organized
- Strong Leadership
- InterQual Certified Expert Reviewer
Certification
IQCER: InterQual Certified Expert Reviewer
BLS: Basic Life Support
Timeline
RN Program Manager Denials & Procedure Specialist
PeaceHealth
08.2022 - 10.2025
RN Case Manager
PeaceHealth Southwest Medical Center
06.2012 - 08.2022
Registered Nurse in Emergency Department
PeaceHealth Southwest Medical Center
08.2001 - 06.2012
Registered Nurse in Emergency Department
Kapiolani Medical Center
09.1998 - 08.2001
Registered Nurse in Emergency Department
Kahu Malama Nurses
01.1998 - 08.1998
Registered Nurse in Emergency Department
Southwest Washington Medical Center
12.1995 - 12.1997
Registered Nurse
Oregon Health Sciences University
09.1995 - 03.1997
Bachelor of Science - Nursing
University of Portland