Joy Walton
Summary
Smart Utilization Review Nurse considered critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare/Medicaid/Commerical guidelines. Known for having great rapport with providers and insurance carriers with over 11 years of expertise in the healthcare industry. Currently enrolled in medical coding program at Penn Foster to prepare to take CPC certification exam.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
Select Health
04.2012 - 11.2023
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Supported organizational growth and development through effective collaboration with interdisciplinary teams focused on improving the quality, safety, and efficiency of healthcare delivery.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Supported data-driven decision-making by regularly analyzing trends in resource utilization, identifying opportunities for improvement, and implementing best practices.
- Performed prior authorization review of services requiring notification.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
Staff Registered Nurse
Intermountain Medical Center
01.2001 - 04.2012
- Worked within interdisciplinary health care team to develop, implement and make adjustments to patient care plans, individualizing strategies, and methods to improve health and meet recovery goals.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Managed elements of patient care from admission to discharge or transfer to other units.
- Gathered patient health data through interviews and observation, documenting data in electronic records.
- Updated patient charts with data such as medications to keep records current and support accurate treatments.
- Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
- Effectively prioritized assignments, executing care based on each patient's relative condition and delegating tasks to available personnel deliver safe and efficient care.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Implemented medication and IV administration, catheter insertion, and airway management.
- Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches.
- Enhanced patient safety by conducting thorough assessments, identifying potential risks, and addressing concerns promptly.
- Served as a strong advocate for patients'' rights, ensuring that their needs were met in accordance with ethical guidelines and regulatory requirements.
- Increased patient satisfaction by consistently delivering high-quality nursing care with a focus on empathy, communication, and professionalism.
- Provided emotional support for patients and families during difficult times, helping them navigate the healthcare system with compassion and understanding.
- Collected blood, tissue, and other laboratory specimens and prepared for lab testing.
- Reduced medication errors through meticulous charting and double-checking dosages.
Education
Bachelor of Science - Nursing
College of Our Lady of The Elms
Chicopee, MASkills
- Procedures Compliance
- Obtaining Authorizations
- Benefits Guidelines
- Utilization Review
- Microsoft Office
- Interpersonal and Written Communication
- Record Analysis
- CPT Coding
- Determine Medical Necessity
- ASAM
- Interqual
- Medicare LCD/NCD's
Certification
- Medical/Coding Training - Currently enrolled with Penn Foster.
Timeline
Utilization Review Nurse
Select Health
04.2012 - 11.2023
Staff Registered Nurse
Intermountain Medical Center
01.2001 - 04.2012
Bachelor of Science - Nursing
College of Our Lady of The Elms