Kimberly Ippoliti
Registered Nurse
Clifton Park,NY
Summary
Self-motivated professional promoting attention to detail and the drive to resolve issues effectively. Calm and poised in the most stressful environments. Seeking the opportunity to join new organization in the role of Utilization Review Nurse. Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
8
8
years of professional experience
Work History
Utilization Review Nurse
Aetna, a CVS Health
Woonsocket, RI
10.2018 - Current
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Provided education to providers regarding utilization management processes and protocols.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Developed case management plans based on individual patient needs and eligibility criteria.
- Performed discharge planning including referrals for post-acute care services when appropriate.
- Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions.
- Identified opportunities for improvement within the utilization review process through data analysis.
- Coordinated with other departments within the organization regarding changes in policy or procedure implementation.
- Attended conferences and training sessions related to utilization review topics such as best practices or new technologies.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Reviewed patient admissions to determine medical necessity as directed by MCG criteria.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Referred cases to secondary review for failure to meet MCG criteria.
- Collaborated with medical directors in group meetings to identify issues and find cost-effective solutions.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Case Manager
CDPHP
Albany, NY
05.2016 - 10.2018
- Assessed clients' needs, developed service plans and monitored progress towards goals.
- Developed individualized care plans with input from clients and their families.
- Collaborated with medical professionals to coordinate treatment plans for clients.
- Maintained accurate case records and documentation according to agency guidelines.
- Compiled reports on cases and submitted them to supervisors as required.
- Counseled clients on available resources within the community that could help meet their needs.
- Monitored client progress through regular follow-up contacts.
- Participated in interdisciplinary team meetings to discuss treatment options.
- Educated clients about mental health conditions, medications and self-care techniques.
- Participated in professional development activities related to case management best practices.
- Maintained up-to-date case records with case activity status.
- Developed trusting relationships with social services, health care providers and governmental agencies.
Education
Associate of Science - Nursing Science
Ellis Hospital School of Nursing
Schenectady, NY05-2003
Skills
- Prior Authorization
- HIPAA Compliance
- Performing assessments
- Utilization review
- Inpatient Care
- Insurance Verification
- Patient transfers and transitions
- Documentation And Reporting
- Quality Improvement
- Utilization Management
- Patient Care Plans
- Records analysis
- Discharge Planning
- Wound Care
- Infection Control
- Chronic Disease Management
- Documentation
- Case Management
- Patient Examination
- Problem-Solving
- Adaptability and Flexibility
- Reliability
- Specialized Healthcare Referrals
- Medication Administration
- Medication and IV administration
- Microsoft Office
- Training staff
- Task Prioritization
- Strong Clinical Judgment
Timeline
Utilization Review Nurse
Aetna, a CVS Health
10.2018 - Current
Case Manager
CDPHP
05.2016 - 10.2018
Associate of Science - Nursing Science
Ellis Hospital School of Nursing
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