Kathy Brown
Denver,NC
Summary
Reliable Utilzation Review Nurse bringing many years of experience in healthcare environments. Maintains positive relationships with case managers and providers. Remains polished and calm under extreme stress.
Overview
17
17
years of professional experience
Work History
Utilization Review Management
Maestro Health/ Marpai Health
01.2019 - Current
- Performs utilization review for medical necessity as based on Milliman Guideline for pre-certification, admission and/or concurrent, retrospective UR review
- Performs utilization review in accordance with DOL/ERISA guidelines as well as any applicable state mandates
- Refers to Independent Organization any case where screening by the nurse does not meet medical necessity criteria and ensures a timely decision is rendered by the Peer Reviewer. Managed Denials and Appeals.
- Promotes and coordinates cost-effective health care services based on medical necessity while delivering the highest quality of care in accordance with case management principles.
Utilization Review/ Case Management/ Personal Health Nurse
InforMed Medical Management/ Conifer Health Solutions
01.2010 - 01.2019
- Performed utilization review based on Milliman Guideline for pre-certification and pre-notifications on various participants under designated group health contracts
- Promoted and coordinated cost-effective health care services based on medical necessity while delivering the highest quality of care in accordance with case management principles
- Performed case management process, by assessment, working with the participant, family, and physician to identify problems, establish goals and develop plans of care, coordinate services, educate and empower the participant to independently self-manage and to make knowledgeable health care decisions.
Hospital Liaison/Transitional Care Coach/ Nurse Case Manager
Community Care Partners of Greater Mecklenburg (CCPGM)
01.2008 - 01.2010
- Identified high cost/ high risk Medicaid/ Medicare patients
- Provided discharge planning from hospital/ acute care setting to home environment
- Completed medication reconciliation and comprehensive health assessment
- Performed utilization review, resource management, care facilitation, crisis intervention, referral to other levels of care, information/community resource linkage for patient and support system.
Education
Bachelor of Science in Nursing -
Radford University
Radford, Virginia05.1987
Skills
- HIPAA Compliance
- Utilization Management/ Case Management
- Case Review Expertise
- Healthcare regulations
- Proficient ICD-10, CPT codes
- Discharge planning coordination
- Clinical assessment
Timeline
Utilization Review Management
Maestro Health/ Marpai Health
01.2019 - Current
Utilization Review/ Case Management/ Personal Health Nurse
InforMed Medical Management/ Conifer Health Solutions
01.2010 - 01.2019
Hospital Liaison/Transitional Care Coach/ Nurse Case Manager
Community Care Partners of Greater Mecklenburg (CCPGM)
01.2008 - 01.2010
Bachelor of Science in Nursing -
Radford University
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