Summary
Overview
Work History
Education
Skills
Timeline
Generic

Kate Novak

Wallagrass

Summary

Dynamic Nurse Reviewer with extensive experience at Gainwell Technologies, excelling in utilization management and clinical documentation. Proven ability to enhance patient outcomes through effective case management and regulatory compliance. Recognized for delivering exceptional customer service while utilizing evidence-based guidelines to drive informed decisions and recommendations.

Overview

15
15
years of professional experience

Work History

Nurse Reviewer

Gainwelltechnologies.com
Remote Worker
12.2021 - Current
  • Evaluated appeals submitted by providers on denied claims and recommended appropriate action.
  • Approached customers and engaged in conversation through use of effective interpersonal and people skills.
  • Utilized evidence-based guidelines to support utilization review decisions and recommendations.
  • Collaborated with staff members in group meetings to identify issues and find cost-effective solutions.
  • Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
  • Provided education to providers regarding utilization management processes and protocols.
  • Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.

Care Coordinator

Brigham and Women Hospital
Boston
01.2014 - 04.2019
  • Provided case management services to ensure the delivery of quality care.
  • Maintained awareness of government regulations, health insurance changes and financing options.
  • Assisted in the development of discharge plans for clients transitioning out of care programs.
  • Attended meetings with families and other members of the interdisciplinary team to discuss patient progress and plan for future interventions.
  • Educated clients on available resources and services within their communities.

RN Case Manager

Tufts Health Plan
Watertown
05.2011 - 12.2013
  • Actively participated in multidisciplinary rounds discussing complex cases with members of the healthcare team.
  • Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
  • Identified high-risk cases requiring intensive monitoring or specialized interventions.
  • Referred patients to specialized health resources or community agencies to furnish additional assistance.
  • Developed discharge plans for patients transitioning from acute care settings to home or alternate facilities.
  • Facilitated referrals to community resources for additional support services.
  • Coordinated discharge planning to ensure continuity of care post-hospitalization.
  • Collaborated with physicians, nurses, and other healthcare professionals to ensure optimal patient outcomes.

Nurse Reviewer

HMS Permedion
Boston
07.2010 - 05.2011
  • Conducted pre and post payment reviews using IQ to determine medical necessity.
  • Performed pre-admission screening reviews to determine coverage eligibility for elective inpatient hospitalization admissions and acute rehabilitation services.
  • Assisted with customer requests and answered questions to improve satisfaction.

Education

Bachelor of Science - Nursing

Adelphi University
Garden City, NY
05-1986

Skills

  • Utilization management
  • Clinical documentation
  • Evidence-based guidelines
  • Case management
  • Regulatory compliance
  • Customer service

Timeline

Nurse Reviewer

Gainwelltechnologies.com
12.2021 - Current

Care Coordinator

Brigham and Women Hospital
01.2014 - 04.2019

RN Case Manager

Tufts Health Plan
05.2011 - 12.2013

Nurse Reviewer

HMS Permedion
07.2010 - 05.2011

Bachelor of Science - Nursing

Adelphi University

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Kate Novak