ACMP
Smart dependable Utilization Review Nurse promoting over a decade of expertise in healthcare industry. Knowledgeable in admissions, extended stays, denials and appeals. Well-versed in Medicare, Medicaid, HMO and PPO.
Hi, I’m
Julie Stemen, RN
Van Wert,OH
Summary
Overview
15
years of professional experience
Work History
Anthem
Utilization Review Registered Nurse
10.2020 - Current
Job overview
- Performed prior authorization review of services requiring notification and medical necessity.
- Performed admission reviews based on medical necessity reviewed against MCG, Medical policies, and Carelone for Medicaid and Medicare.
- Maintained all utilization review documentation through ACMP, Facets and Maces.
- Performed audits of internal operating procedures to ensure compliance with industry guidelines as well as alignment with organizational productivity goals.
- Maintained 100% productivity measured against company required case load.
Omnicare/ CVS
Field Nurse Consultant
07.2017 - 10.2020
Job overview
- Evaluate regulatory compliance and determine clinical education needs for Ohio/Indiana region of clients as it relates to pharmacy services.
- Conduct quality assurance audits to aid clients with preparation for successful and compliant state surveys.
- Assist with activities associated in onboarding new facilities such as collection of resident information and medical records; scheduling, attending, and some facilitation of facility staff training; informing pharmacy of facility needs; serving as single point of contact for facility throughout onboarding process.
HCFS Inc.
Case Manager/Utilization Review Nurse
07.2016 - 07.2017
Job overview
- Addressed disruptions in patient care, including delays in discharge, postponed procedures and discharge equipment availability.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed prior authorization in preparation of admissions and updates on clinical and therapy progress for next review date.
- Attended and lead care conferences for families and patients to keep them up to date on their progress , care and remaining insurance coverage.
Lima Memorial Health System
Dialysis Registered Nurse
03.2016 - 03.2017
Job overview
- Set up and operated dialysis machines for patients receiving treatment for kidney failure.
- Explained dialysis procedures and hemodialysis machine operation to patients prior to treatment to ease anxieties.
- Started and ended reverse osmosis water systems and completed water quality monitoring tests.
VanCrest Of Convoy
Director of Nursing
07.2015 - 07.2016
Job overview
- Direct day-to-day administrative and operational functions for 40 bed facility, providing guidance and leadership to employees across all departments.
- Generated and reviewed incident reports, including employee write-ups, actualizing appropriate corrective action plans to mitigate ongoing and potential situations.
- Managed payroll for organization personnel by oversaw day-to-day processing of payroll for employees, including review of timesheets.
- Assisted staff nurses and aides with the care of patients .
Van Wert County Hospital
Case Manager /Utilization Review Nurse
07.2012 - 07.2016
Job overview
- Gathered clinical information and applied the appropriate clinical criteria and clinical judgment to render impatient vs observation admission status.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
- Performed prior authorization review of services requiring notification.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Supported or performed clinical appeals.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
Van Wert County Hospital
Staff Nurse
03.2009 - 07.2012
Job overview
- Cared for wounds, provided treatments and assisted with procedures.
- Collaborated with physicians to assess patient needs, plan and modify care and implement interventions.
- Identified patient care requirements by establishing personal rapport in efforts to comfort and counsel patients and families.
- Provided high level of individualized care to adult patients across multiple medical specialties.
- Administered controlled narcotics, inserted IVs and performed catheterizations.
Education
Indiana State UniversityTerre Haute, IN
Bachelor of Science from Registered Nurse
2012
University Overview
Rhodes State CollegeLima, OH
Licenced Practical Nurse
2008
University Overview
Skills
- Medicare and Medicaid
- Excellent administrative abilities
- Analyzing documentation
- Fluent in MCG and Interqual criteria
- Able to navigate and review Carelone criteria
- Insurance claims and denial processes
- Prior authorization processing
- EMR / EHR documentation and navigation
- Reviewing patient medical records for compliance with healthcare standards
- Inter-Rater Reliability (IRR) regulatory compliance
- Establishing medical necessity in regards to claims
Work Preference
Work Type
Full TimeLocation Preference
RemoteImportant To Me
Company CultureWork-life balanceCareer advancementPaid sick leaveHealthcare benefits401k matchPaid time offFlexible work hoursWork from home optionLicense
License
Ohio Board of Nursing Registered Nurse Multistate Licensure
Software
MCG
Interqual
Timeline
Utilization Review Registered Nurse
Anthem
10.2020 - Current
Field Nurse Consultant
Omnicare/ CVS
07.2017 - 10.2020
Case Manager/Utilization Review Nurse
HCFS Inc.
07.2016 - 07.2017
Dialysis Registered Nurse
Lima Memorial Health System
03.2016 - 03.2017
Director of Nursing
VanCrest Of Convoy
07.2015 - 07.2016
Case Manager /Utilization Review Nurse
Van Wert County Hospital
07.2012 - 07.2016
Staff Nurse
Van Wert County Hospital
03.2009 - 07.2012
Indiana State University
Bachelor of Science from Registered Nurse
Rhodes State College
Licenced Practical Nurse