Enjoy reading for overall mental well being as well as to keep myself educated on various topics
Enjoy traveling and sharing findings and experiences
Judy Babcock
Cibolo,USA
Summary
Dedicated Registered Nurse with over 15 years of experience in remote utilization review and medical review, demonstrating strong proficiency in medical record evaluation, CMS regulations, and Medicare Advantage plans. Recognized as a results-oriented professional thriving in both independent and collaborative environments, consistently driving team success and enhancing operational efficiency. Expertise in various software platforms, including Microsoft Suite and Google Docs, supports productivity and effective workflow management. A proven track record of exceeding organizational objectives while contributing to the development of streamlined processes underscores a commitment to excellence in healthcare delivery.
Overview
16
16
years of professional experience
Work History
UR Nurse Reviewer, RN
Evolent Health Plan
Arlington, VA
11.2020 - Current
- Oversaw operations for four distinct health plans, consistently surpassing productivity benchmarks by 10%-15%.
- Developed and presented tailored training modules to boost effectiveness and integration of newly hired team members.
UR Nurse Reviewer/ UM Oversight RN
Clover Health Plan
San Francisco, CA
09.2017 - Current
- Processed authorization requests including DME, concurrent and retrospective reviews, Pre-Service, Inpatient, Outpatient, Diagnostic Imaging, Labs, Genetics testing, Oncology, SNF, LTACH, Acute Rehab, Psychiatric and Home Health services by applying appropriate guidelines using MCG, Interqual, CMS and state mandates
- Applied appropriate guidelines using MCG, CMS and state mandates
- Effectively analyzed and guided level of care by applying appropriate MCG, CMS and State mandates
- Monitored project timelines to consistently fulfill contractual commitments.
- Performed oversight management and partnership with UM vendors
- Researched and analyzed records to ensure proper determination
- Completed monthly clinical Quality Assurance and spot monitoring reports to address areas of improvement
- Created and implemented work processes and training for MDs, new hires and vendors
- Collaborated in development of Standard Operating Procedures (SOP)
- Achieved successful training of new vendors
- Implemented User "Quick Reference Document" to assist MDs and RN reviewers in Pain Management reviews (effectively decreasing discordance and appeals)
RN Reviewer/3rd Party Review
Mitchell International
San Diego, CA
01.2013 - 07.2017
- Reviewed medical, police, EMS, dental records, and accident reports for evaluation of relatedness to 3rd party injury claims
- Performed coding and billing reviews to assess and ensure accuracy in relation to the injury
- Accurately entered billing data into software program
- Performed significant research and analyzed records for purpose of determining relatedness of treatments and clinical diagnoses in relation to reported injury
- Compiled accurate comprehensive, chronological documentation and reports for third party review
- Consistently assisted insurance adjusters in negotiation by consistently meeting deadlines and providing accurate comprehensive, chronological reports and presenting recommendations
Resource Nurse/Utilization Review Nurse
Arcadian Health Plan
Oakland, CA
10.2011 - 12.2012
- Conducted thorough reviews of medical documentation to align client care requirements with cost containment strategies. Accurately exceeded production goals by 15%.
- Documented and presented weekly outcomes of final determinations in levels of care to support informed decision-making.
- Facilitated collaboration between providers and case managers to assess and determine tailored care levels for clients.
- Conducted thorough assessments of billing procedures to ensure accurate documentation within software tracking system.
Case Manager/RN Utilization Review
XL Health
San Antonio, TX
04.2010 - 10.2011
- Effectively guided appropriate level of care for the client by reviewing medical records for both utilization and concurrent review using Milliman and CMS guidelines
- Performed Case Manager duties for assigned case load of 150-225 members for disease and behavioral management
- Educated members regarding chronic condition management and assessed members needs which resulted in reduced hospitalization and increased cost containment
- Communicated and coordinated with social workers, pharmacists, physicians and other case managers to address needs and discharge planning for the client
- Reorganized Utilization Review Department in time of management/department crisis. Was chosen among a group of 5 other nurses (noted to be top performers) to perform restructuring
Education
Associate of Applied Science - Nursing
San Antonio College School of Nursing
San Antonio, TXSkills
- Skilled in ICD-9 and ICD-10 classification
- Electronic medical record analysis
- Analytical problem solver
- Extensive remote work experience
- Knowledge of regulatory compliance
- Analytical and critical thinking
- Knowledge of coding basics
- Data analysis
- Effective communication
- Goal-oriented adaptability
- Critical thinker
- Driven approach to achieving quality outcomes
Accomplishments
- Documentation - Ensured charting accuracy through precise documentation.
Interests
Timeline
UR Nurse Reviewer, RN
Evolent Health Plan
11.2020 - Current
UR Nurse Reviewer/ UM Oversight RN
Clover Health Plan
09.2017 - Current
RN Reviewer/3rd Party Review
Mitchell International
01.2013 - 07.2017
Resource Nurse/Utilization Review Nurse
Arcadian Health Plan
10.2011 - 12.2012
Case Manager/RN Utilization Review
XL Health
04.2010 - 10.2011
Associate of Applied Science - Nursing
San Antonio College School of Nursing