Judith Lemuz
Registered Nurse
Wichita,KS
Summary
Seasoned Registered Nurse with over 25 years of experience in clinical and management roles, specializing in patient care and IT healthcare solutions. Expertise in conducting thorough member record reviews to ensure high quality treatment standards are provided. Proficient in surgical procedures, pre-certification processes, retrospective analysis, and managing diverse healthcare programs. Compact licensure, which enables enhanced review capabilities across multiple states for comprehensive healthcare delivery. Currently pursuing an MSN in Nursing Education to further advance knowledge and impact in the nursing field.
Overview
11
11
years of professional experience
2
2
Certifications
2
2
Languages
Work History
SCA Clinical Claim Reviewer, RN
Optum Serve (UnitedHealth Group)
06.2023 - Current
- Evaluated healthcare documentation for compliance and quality assurance, providing actionable feedback to enhance standards.
- Coordinated with cross-functional teams to streamline review processes, resulting in improved workflow efficiency.
- Maintained strong attention to detail while reviewing numerous documents daily, ensuring consistent quality and accuracy.
- Promoted collaboration and continuous improvement among team members, fostering a culture of quality and accountability.
- Maintained strict confidentiality with sensitive client information, adhering to industry standards and company policies.
- Reduced turnaround time for reviews by effectively prioritizing tasks and managing deadlines.
- Conducted in-depth research to strengthen the overall quality and credibility of each review.
- Actively sought opportunities for professional development, attending industry conferences and webinars to expand expertise in relevant fields.
Preservice Review RN, Utilization Management
Optum (UnitedHealth Group)
03.2022 - 06.2023
- Evaluated charts and analyzed clinical documents to ensure compliance with standards and improve accuracy.
- Validated surgical interventions, home health care, DME medications, and office visit requests aligned with applicable plan guidelines.
- Managed inquiries from plan members and medical staff regarding authorization details, ensuring clear communication and prompt responses.
- Engaged with physicians to facilitate patients' coverage processing for planned procedures.
- Reviewed insights derived from interviews, educational and medical records, consultations with other professionals, and diagnostic evaluations to identify clients' strengths, needs, and eligibility for services.
- Delivered patient-centered care and education to diverse populations across various healthcare environments.
- Teamed up with interdisciplinary groups to create and implement tailored care plans.
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Participated in ongoing professional development opportunities to stay current on best practices in nursing care and emerging trends in healthcare delivery.
Utilization Review Nurse
NMC
03.2018 - 03.2022
- Conducted pre-certification, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure.
- Ensured compliance with medical standards for all clients based on specific health benefit plans.
- Guaranteed adherence to management-established rules and regulations to maintain organizational standards.
- Enhanced communication among department heads, medical staff, and administration through strategic meetings and coordination of interdepartmental functions.
- Developed and implemented an efficient system for staff communication
- Mentored and guided new and current employees in skill development.
- Acquired comprehensive knowledge of Medicare guidelines and procedural standards.
- Exhibited expertise in ICD-10 and CPT coding guidelines.
Registered Nurse Manager
RN, Larksfield Place
03.2017 - 03.2018
- Directed patient care operations on post-acute care unit, delivering direct care, assigning nursing tasks, and evaluating performance of 35+ nursing staff
- Established and enhanced policies and procedures to guarantee adherence to HIPAA benefits administration and general liability regulations across local, state, and federal levels.
- Coordinating and managing medications/treatments: trach care, extensive wound care, PIV, PICC, mid-line, oral, IV, IM, and monitoring responses.
- Coached new nurses in techniques, care standards, and safety protocols to advance clinical competency and enhance patient outcomes.
- Reviewed charts and assessed clinical documents to confirm accuracy.
- Directed documentation workflows through software tools to enhance accuracy and efficiency.
- Created effective communication platform facilitating efficient staff exchanges.
Registered Nurse, PACU
Via Christi Village
06.2015 - 08.2017
- Administering and overseeing medication treatments: tracheostomy care, comprehensive wound management, peripheral IV, PICC line, midline catheter, oral, intravenous, intramuscular, and monitoring responses.
- Directed patient care throughout admission and discharge phases, ensuring effective intervention coordination and discharge planning.
- Guided patients and caregivers on implementation of discharge plan objectives for wound management, ensured safe medication practices, disease management, improving patient comprehension and adherence.
- Documentation: Meditech platform and Excel tools.
- Delivered hospice and home healthcare services to enhance patient comfort in personal environments.
- Instructed new nurses regarding adherence to proper techniques, care standards, operational procedures, and safety protocols.
- Analyzed employee skill gaps and implemented targeted training programs fulfilling identified requirements.
Education
Associate of Science - Nursing
Barton County Community College
Great Bend, KSSkills
- Decision-making
- Adaptability and flexibility
- Quality Customer service
- Attention to detail
- Editing and review
- Accuracy and precision
- Team contribution
- Critical thinking
- Work prioritization
- Project collaboration
- Team building and leadership
- Critical analysis
- Project planning
- Idea brainstorming
- Research and interviews
- Creative thinking
- Production deadlines
- Clear communication
- Dependability and cooperation
- Relationship building
- Data entry
- Microsoft office
- Email communication
Certification
BLS Certification, 1999-Aug. 2022
Timeline
SCA Clinical Claim Reviewer, RN
Optum Serve (UnitedHealth Group)
06.2023 - Current
Preservice Review RN, Utilization Management
Optum (UnitedHealth Group)
03.2022 - 06.2023
Utilization Review Nurse
NMC
03.2018 - 03.2022
Registered Nurse Manager
RN, Larksfield Place
03.2017 - 03.2018
Registered Nurse, PACU
Via Christi Village
06.2015 - 08.2017
Associate of Science - Nursing
Barton County Community College