Kendra Torres
LPN
Richmond Hill,GA
Summary
Seasoned nurse offering proven clinical knowledge in prior-authorizations, case management, and claims review. Organized and dependable candidate with willingness to take on added responsibilities to meet team goals.
Overview
8
8
years of professional experience
Work History
Prior Authorization Specialist
Centene
07.2024 - Current
- Inpatient & Outpatient status review
- Apply evidence based criteria to determine authorization outcomes
- Appeals & Peer-to Peer Coordination
- Collaborated with physicians to obtain necessary clinical information for prior authorization submissions.
- Surgical, Diagnostic, Medication, and DME authorization review
- Clear documentation and rationale writing
- Conflict resolution
- Policy interpretation
Prior Authorization Nurse
CommunityCare
01.2020 - 06.2024
- Review of Medical/Surgical/DME/Medications/ and Imaging request for medical necessity per evidence based criteria guidelines InterQual/Medicare Administrative Contractor (MAC)
- Maintain productivity and quality benchmarks in a high-volume review environment
- Escalate complex or non criteria meeting cases to the Medical Director for further review
- Ensure compliance with federal state and payer regulations
Licensed Practical Nurse Case Manager
Global Health Holdings
03.2018 - 01.2020
- Streamlined case management processes to improve efficiency and optimize resource utilization in healthcare setting.
- Reduced hospital readmission rates through closely monitoring patient progress, adjusting treatment plans as needed.
- Collaborated with multidisciplinary teams to develop comprehensive care plans tailored to patients'' specific needs.
- Educated patients and caregivers on disease processes, medications, self-care techniques, and lifestyle modifications to promote optimal health outcomes.
Education
High School Diploma -
Mcloud High School
Mcloud, OK 05.2001 -
License Practical Nurse - Nursing
DeMarge College
OKC, OK 05.2001 -
Skills
Prior Authorization/Utilization Review
Microsoft Office applications
Electronic Health Records/ UM Software
InterQual, CMS, and Commercial Guidelines Application
Data Entry & Documentation Accuracy
Timeline
Prior Authorization Specialist
Centene
07.2024 - Current
Prior Authorization Nurse
CommunityCare
01.2020 - 06.2024
Licensed Practical Nurse Case Manager
Global Health Holdings
03.2018 - 01.2020
High School Diploma -
Mcloud High School
05.2001 -
License Practical Nurse - Nursing
DeMarge College
05.2001 -