Jennifer Readman
Phoenixville,PA
Summary
Experienced Utilization Management Nurse skilled in denial management and care coordination. Facilitated interdisciplinary collaboration to optimize patient outcomes through utilization review and clinical criteria assessment. Committed to resolving complex issues and enhancing care delivery.
Overview
1
1
Certification
28
28
years of professional experience
Work History
Utilization Management Nurse
Children's Hospital of Philadelphia
Philadelphia, USA
01.2019 - Current
- Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation.
- Validated admission and continuing stay criteria with third party payers and attending physicians to ensure alignment with clinical standards.
- Collaborated with third party payers to prevent payment denials and proactively resolved issues impacting approvals.
- Acted to prevent payment denials by resolving issues promptly.
- Educated physicians on denial and appeal processes to enhance understanding and compliance.
- Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.
- Recommends alternative care sites where appropriate.
Case Management Supervisor
Children's Hospital of Philadelphia
Philadelphia, USA
11.2016 - 01.2019
- Provide direct supervision of staff in assigned areas of responsibility including training, development, and recognition and performance management.
- Collaborated with manager to lead and manage departmental operations, overseeing day-to-day activities, planning, and performance management.
- Developed and implemented orientation and mentoring plans for new staff in the department.
- Participates in the establishment and implementation of departmental goals.
- Conducted interviews for departmental positions and recommended candidates to the director for hiring.
Case Manager
Children's Hospital of Philadelphia
Philadelphia, USA
11.2014 - 11.2016
- Facilitated discharge of complex and routine patients from the Cardiac Center through assessment, education, prior authorizations, and transport coordination, ensuring smooth transitions to post-hospital care.
- Collaborated with patient's physician team during utilization review process to secure appropriate reimbursement for patient care.
- Educated physicians regarding the denial and appeal process and facilitated the appeal process.
- Developed strong working relationships with interdisciplinary team members in the Cardiac Center to enhance collaboration and patient outcomes.
Home Care Clinical Nurse Coordinator
Children's Hospital of Philadelphia
Philadelphia, USA
04.2008 - 11.2014
- Worked as a Level IV RN in a Medicare certified Home Care setting.
- Collaborated with interdisciplinary team to ensure smooth transition of patient's care from hospital to home.
- Supervised, oriented, and trained field nurses to improve care delivery in home settings.
- Proficient in OASIS Documentation and Submission.
- Routinely provided direct patient care.
- Trained nurses on EPIC software usage to enhance patient care coordination. for Home Care RN’s and Respiratory Therapists.
Clinical Staff RN, PICC Team
Hospital of the University of Pennsylvania
Philadelphia, USA
02.2006 - 04.2008
- Performed ultrasound guided bedside placement of PICC lines using the Modified Seldinger Technique.
- Assessed and evaluated patients referred for bedside PICC Line or midline placement.
- Educated patients and families on risk and benefits of the procedure.
- Created and delivered in-service training for staff nurses on central line care and differentiation between PICC lines and midlines.
- Developed pilot program for central line care and maintenance, aimed at reducing bloodstream infections.
- Performed daily maintenance of central lines in pilot units, ensuring compliance with care protocols.
Home Infusion RN
Pediatric Services of America, Inc.
Bensalem, USA
01.2000 - 02.2006
- Delivered ongoing care for pediatric and adult patients receiving home infusion therapy, specializing in hemophilia management.
- Administered diverse therapies, including antibiotics, hydration, TPN, chemotherapy, IVIG, pain control, sq medications, line maintenance, enzyme replacement, and enteral therapies, ensuring comprehensive patient treatment.
- Established and maintained tracking system for maintenance and repair of durable medical equipment, enhancing operational reliability.
Traveling RN
Travcorps, Inc.
Malden, USA
04.1999 - 01.2000
Clinical Staff RN
Department of the Army
Honolulu, USA
11.1998 - 03.1999
- Planned, coordinated, and evaluated complex multicultural nursing care encompassing chemotherapy, pain management, respiratory and metabolic disorders, and pre & postoperative care.
- Provided nursing care to patients on a surgical/oncology unit on a 22 bed surgical/oncology unit.
- Supervised and trained up to ten staff members, including 3-4 orientees, students, and reservists during rotating shifts.
Clinical Staff RN
Johns Hopkins Medical Center
- Delivered direct patient care on pediatric oncology/bone marrow transplant unit, ensuring comprehensive support for patients' physical and emotional needs.
- Administered medication and chemotherapy, while executing daily patient care tasks to maintain health and comfort.
- Educated families and patients on diagnosis, medication, and treatment options to empower informed decision-making.
Staff Nurse
Capital Health System
Trenton, New Jersey
- Delivered comprehensive care on general pediatric inpatient unit, ensuring patient comfort and well-being.
- Educated patients and families on health management, fostering understanding and adherence to treatment plans.
- Administered medications and treatments as prescribed by physicians.
- Collaborated with healthcare team to develop patient care plans.
- Monitored patient vital signs and reported changes to medical staff.
Education
Bachelor of Science Degree - Nursing
Thomas Jefferson University
Philadelphia, PA01-1994
Skills
- Utilization review
- Denial prevention
- Clinical assessment
- OASIS reporting
- Care coordination
- Team collaboration
Certification
Registered Nurse, PA
Timeline
Utilization Management Nurse
Children's Hospital of Philadelphia
01.2019 - Current
Case Management Supervisor
Children's Hospital of Philadelphia
11.2016 - 01.2019
Case Manager
Children's Hospital of Philadelphia
11.2014 - 11.2016
Home Care Clinical Nurse Coordinator
Children's Hospital of Philadelphia
04.2008 - 11.2014
Clinical Staff RN, PICC Team
Hospital of the University of Pennsylvania
02.2006 - 04.2008
Home Infusion RN
Pediatric Services of America, Inc.
01.2000 - 02.2006
Traveling RN
Travcorps, Inc.
04.1999 - 01.2000
Clinical Staff RN
Department of the Army
11.1998 - 03.1999
Staff Nurse
Capital Health System
Clinical Staff RN
Johns Hopkins Medical Center
Bachelor of Science Degree - Nursing
Thomas Jefferson University