Experienced and results-driven Registered Nurse with over 6 years of comprehensive clinical and case management experience. Specializes in utilization review, care coordination, and optimizing patient care through evidence-based decision-making. Proficient in assessing medical necessity, reviewing clinical documentation, and ensuring compliance with treatment protocols by working closely with insurance providers. Skilled in utilizing EMR systems such as EPIC. Possesses strong communication and leadership skills. Excels at collaborating with multidisciplinary teams to improve healthcare outcomes while effectively controlling costs and maintaining quality care standards.
• Perform utilization reviews of inpatient and outpatient services to ensure the medical necessity of treatments and compliance with insurance guidelines.
• Conduct concurrent reviews for inpatient care, identifying opportunities for cost reduction without compromising quality.
• Collaborate with physicians, case managers, and other healthcare providers to ensure timely and appropriate care transitions.
• Review clinical documentation for accuracy and completeness, providing feedback for improvement where necessary.
• Process prior authorization requests and review insurance company denials, ensuring all actions are in line with regulations and guidelines.
• Work with multidisciplinary teams to develop strategies that reduce unnecessary treatments and optimize resource use.
Utilization Review/Management
Case Management
Insurance Authorization & Denials
Clinical Documentation & Charting
EMR Systems (EPIC, Home Care Home Base, WellSky)
Care Coordination
Prior Authorization & Concurrent Review
Treatment Planning & Discharge Planning
Managed Care & Compliance
Collaboration & Teamwork
Patient Advocacy & Education
Cost Control & Resource Management
Leadership/Charge Nurse
• Registered Nurse License – Michigan (#470433627)
• Compact Nursing License – Arkansas (#221988)
BLS
Additional Information
• Telehealth & Remote Patient Monitoring: Experience in telehealth roles and remote patient assessments.
• Quality Improvement: Active involvement in hospital quality improvement initiatives to enhance care delivery and patient outcomes.
• Fluent in Electronic Health Records (EHR): Proficient in EPIC and other clinical management systems for documentation, reporting, and case management.
Family
Work- life balance
Education
• Registered Nurse License – Michigan (#470433627)
• Compact Nursing License – Arkansas (#221988)
BLS
Additional Information
• Telehealth & Remote Patient Monitoring: Experience in telehealth roles and remote patient assessments.
• Quality Improvement: Active involvement in hospital quality improvement initiatives to enhance care delivery and patient outcomes.
• Fluent in Electronic Health Records (EHR): Proficient in EPIC and other clinical management systems for documentation, reporting, and case management.