Jennifer Weiler
Cincinnati,OH
Summary
Self-motivated professional promoting attention to detail and the drive to resolve issues effectively. Calm and poised in the most stressful environments. Seeking the opportunity to join new organization in the role of Denial Prevention Nurse Consultant.
Overview
7
7
years of professional experience
Work History
Utilization Review Nurse
The Urology Center
Cincinnati, OH
07.2024 - Current
- Provided education to providers regarding utilization management processes and protocols.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Generated reports related to utilization management activities such as length of stay trends, denials rates.
- Investigated complaints related to denied claims or treatment plans.
Utilization Review Nurse
Best Surgery Center
Cincinnati, Ohio
09.2022 - 10.2023
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Maintained up-to-date knowledge of changes in healthcare regulations, policies, and evidence-based practices.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Identified opportunities for improvement within the utilization review process through data analysis.
Utilization Review Nurse
UC Health
Cincinnati, OH
07.2019 - 09.2022
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Generated reports related to utilization management activities such as length of stay trends, denials rates.
- Identified opportunities for improvement within the utilization review process through data analysis.
- Communicated with external partners such as managed care organizations or vendors on a regular basis.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Referred cases to secondary review for failure to meet criteria.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Participated in multidisciplinary team meetings to discuss patient care issues and utilization review findings.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Managed appeals for denied services, providing additional information to support medical necessity.
- Ensured compliance with federal, state, and accreditation requirements related to utilization management.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Utilization Review Nurse
Jewish Hospital
Cincinnati, OH
10.2017 - 07.2019
- Managed processes pertaining to denials and potential denials as outlined by insurance carriers.
- Worked with insurance companies and patients to determine best courses of action.
- Conducted complex research, review and analysis of medical records, treatment plans and claim information.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
Education
Associate Degree in Nursing - Nursing
Galen College of Nursing
Louisville, KY06.2013
Some College (No Degree) - Marketing
Cincinnati State Technical And Community College
Cincinnati, OHSkills
- Quality improvements
- Interpersonal and written communication
- Utilization Review
- Healthcare Personnel Supervision
- Utilization review
- Documentation And Reporting
- Medicaid knowledge
- Communication
- Records analysis
- Accurate Documentation
- Critical Thinking
- Specialized Healthcare Referrals
- Creative Problem Solving
Timeline
Utilization Review Nurse
The Urology Center
07.2024 - Current
Utilization Review Nurse
Best Surgery Center
09.2022 - 10.2023
Utilization Review Nurse
UC Health
07.2019 - 09.2022
Utilization Review Nurse
Jewish Hospital
10.2017 - 07.2019
Associate Degree in Nursing - Nursing
Galen College of Nursing
Some College (No Degree) - Marketing
Cincinnati State Technical And Community College
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