Karen Provence
Southaven
Summary
Detail-oriented professional with a strong background in medical record review and clinical documentation analysis. Proven ability to support prior authorization determinations and ensure compliance with regulatory standards.
Overview
6
6
years of professional experience
Work History
Virtual Utilization Review Nurse
Ensemble Health Partners
Blue Ash
09.2025 - Current
- Review patient records for medical necessity and appropriateness of care.
- Communicate with healthcare providers to clarify treatment plans and authorizations.
- Utilize electronic health record systems to document utilization review findings.
- Analyze clinical information to support authorization decisions for services.
- Support compliance with regulatory guidelines during the review process.
- Apply medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Conduct reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Collaborate with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
Remote Utilization Review Nurse
Methodist Le Bonheur Healthcar
Memphis
03.2020 - 09.2025
- Conducted comprehensive reviews of patient treatment plans and medical records.
- Collaborated with healthcare teams to ensure appropriate resource utilization.
- Assessed clinical documentation for compliance with regulatory standards and policies.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Coordinated with other departments within the organization regarding changes in policy or procedure implementation.
- Communicated with external partners such as managed care organizations or vendors on a regular basis.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Documented all utilization review activities, findings, and decisions in patient records and databases.
Education
Bachelor of Science - Nursing
Union University
Jackson, Tennessee, TN05.2007
Diploma - Nursing
Baptist School of Nursing
Memphis, TN05.1984
Skills
- medical record review
- clinical documentation analysis
- electronic health records
- utilization management
- insurance authorization
- effective communication
- attention to detail
- critical thinking
- time management
- Teamwork and collaboration
- Communication
- Prior authorization
- InterQual criteria
- Utilization review
Timeline
Virtual Utilization Review Nurse
Ensemble Health Partners
09.2025 - Current
Remote Utilization Review Nurse
Methodist Le Bonheur Healthcar
03.2020 - 09.2025
Bachelor of Science - Nursing
Union University
Diploma - Nursing
Baptist School of Nursing