Kathy Hogue

• I am currently working as a Medical Reviewer III at Blue Cross Blue Shield of SC in the Federal Employee Program, as a utilization review nurse.
• I have been in this position for almost 9 years and prior to this department, I worked as utilization review nurse for the pre-certification area for 6.5 years. Current duties involve reviewing pre-determination cases and post service claims for medical necessity, cosmetic, investigational status, review for appropriate length of stay, procedure and services. Review for correct and appropriate cost and billing along with looking for duplications in billing is also part of my daily tasks .
• Looking closely at policy and procedures for meeting medical necessity criteria and if unable to make determinations with this info, cases are forwarded to the Physician for review. They can then make a determination or request the case to be submitted to an outside review company for specialty matched review and I am responsible for submitting all info to the appropriate specialty reviewer and then following up when completed.
• I am responsible for completing Medical Savings/Cost savings report each month, which documents claims or partial claims that have been denied based on the medical review completed. Monthly savings averages $150,000.00.
• I work well alone or with others as needed. I am a self motivator, have excellent time management skills and I am able to prioritize my workload to complete most urgent items and meet timeliness standards or deadlines.
• Current workloads can range from 20-200 cases daily, complete 50 or more pre-determinations per month. Monthly savings averages $150,000.00 per month.
• Phone/computer skills
• Record management

Secured controlled narcotics and distributed medication on schedule to meet patient needs and minimize misuse opportunities.

• Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
• Kept optimal supply levels in treatment rooms, triage and other areas to meet typical patient loads.
• Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
• Direct patient care and treatment. Worked with the physician to produce the best outcome for the patient and their family.
• Triage nurse, charge nurse, preceptor.