Years of Utilization Review Experience
Kelly Huffer
Registered Nurse
Lake Charles,LA
Summary
●Five years of experience in Utilization Review Nurse /Case Manager
●Knowledgeable MIlliman/InterQual
●Monitor Inpatient and Observation for medical necessity
●Recognized consistently for performance excellence
Overview
5
5
Work History
Utilization Review Nurse/RN Case Manager
CHRISTUS Ochsner St. Patrick
LAKE CHARLES , United States
2017.10 - Current
- Conduct admission reviews, concurrent reviews and retrospective reviews around 25-50 per day. Report avoidable delays based on medical records review.
- Identify inappropriate utilization of services/settings through application of establish clinical criteria using InterQual and Milliman guidelines for medical necessity.
- Proactively speak with ED doctors or Hospitalist if patients , do not have appropriate status order.
- Discuss with physician advisor if review criteria are not met, or if when met, there is concern about level of care based on complexity of patient’s conditions or questions about quality of care.
- Collaborates with senior case manager and physician advisor if attending doctor needs to be notified of denial and in regards to trying to overturn denial with peer-to-peer process.
- Communicate with payers in regards to clinical information to ensure support of medical necessity/level of care to successfully avoid or reverse denials.·
Education
Associate of Science - Nursing
New Mexico College
Hobbs, NM12.1989
Skills
- Proficient in InterQual/Milliman screening tool
- Daily Utilization Review for Commercial and Medicaid patients
- Daily Monitoring of Inpatient and Observation patients for medical necessity
- Coordinating pre-and post- discharge peer to peer reviews.
- Managing pre-and post-discharge reconsiderations and denials
- Observation billing
- 1-2 Day Stays for medical necessity
- Willingness to learn
- Excellent team player
- Excellent written and verbal communication skills
Timeline
Utilization Review Nurse/RN Case Manager
CHRISTUS Ochsner St. Patrick
2017.10 - Current
Associate of Science - Nursing
New Mexico College
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