Jessica Craig
Pana,IL
Summary
Dynamic Utilization Review Registered Nurse with extensive experience at HSHS, adept at determining medical necessity and ensuring compliance with healthcare regulations. Proven ability to communicate effectively with interdisciplinary teams and patients, enhancing treatment authorization processes. Skilled in electronic health records management and critical thinking, driving improved patient care outcomes.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Utilization Review Registered Nurse
Ensemble Health Partners
Cincinnati, Ohio
04.2025 - Current
- Assessed medical records to determine the necessity of ongoing treatments.
- Analyzed clinical data to ensure adherence to insurance guidelines and policies.
- Maintained knowledge of current healthcare regulations and reimbursement practices.
- Conducted retrospective reviews of medical cases as needed to evaluate appropriateness of care provided.
- Prepared written summaries detailing findings from utilization review activities upon request.
- Performed concurrent reviews of medical records during active episodes of care.
- Responded promptly to inquiries regarding authorization requests from providers or patients.
- Maintained detailed documentation of all utilization review activities according to applicable standards.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
Utilization Review Registered Nurse
HSHS
Springfield, Illinois
09.2018 - 04.2025
- Collaborated with healthcare teams to coordinate patient services and resources.
- Assessed medical records to determine the necessity of ongoing treatments.
- Communicated with patients to explain utilization review processes and requirements.
- Documented findings and recommendations in electronic health record systems.
- Participated in interdisciplinary meetings to discuss patient care strategies and outcomes.
- Maintained knowledge of current healthcare regulations and reimbursement practices.
- Prepared written summaries detailing findings from utilization review activities upon request.
- Performed concurrent reviews of medical records during active episodes of care.
- Responded promptly to inquiries regarding authorization requests from providers or patients.
- Compiled monthly reports documenting changes in resource use patterns over time.
- Provided training on proper completion of authorization forms for staff members at participating facilities.
- Collaborated with physicians, case managers and other healthcare professionals to ensure appropriate utilization of services.
- Assisted with developing new processes or protocols related to utilization management functions.
Registered Nurse House Supervisor
HSHS St. Joseph's Hospital
Breese, Illinois
09.2018 - 04.2020
- Supervised nursing staff to ensure quality patient care standards.
- Completed daily rounds of nursing department to verify nursing service personnel performance alignment acceptable nursing standards.
- Investigated and reported accidents, leveraging new knowledge to improve protections for patients and staff.
- Maintained correct number of staffers to meet budget parameters while promoting high levels of patient care.
- Answered questions and addressed concerns from employees promptly through email, phone and in person.
- Maintained comprehensive base of unit supplies to meet expected patient demands, public health emergencies, and mass casualty incidences.
- Monitored staffing levels throughout shifts and made adjustments based on patient acuity levels.
- Collaborated with other departments within the facility including pharmacy, laboratory services, dietary services.
- Responded quickly during emergency situations while maintaining composure under pressure.
Education
Bachelor of Science - Nursing
Chamberlain College of Nursing
Addison05-2021
Skills
- Medical necessity determination
- Electronic health records management
- Treatment authorization
- Effective communication
- Medicaid and Medicare knowledge
- Compliance procedures and guidelines
- Utilization management strategies
- HIPAA compliance expertise
- Critical care nursing skills
- Problem-solving abilities
- Critical thinking capabilities
Accomplishments
- Daisy Award Recipient 2018
Certification
- MCG Certified
- Illinois RN License Active
- Wisconsin RN License active
Timeline
Utilization Review Registered Nurse
Ensemble Health Partners
04.2025 - Current
Utilization Review Registered Nurse
HSHS
09.2018 - 04.2025
Registered Nurse House Supervisor
HSHS St. Joseph's Hospital
09.2018 - 04.2020
Bachelor of Science - Nursing
Chamberlain College of Nursing