Kimberly Kelly-Budd
Leesburg,VA
Summary
Dynamic Utilization Review Nurse with extensive experience, adept in applying InterQual, MCG criteria and/or CMS policies to enhance patient care while reducing costs. Proven ability to collaborate with healthcare teams and maintain compliance with policies. Skilled in documentation and reporting, with a strong commitment to quality assurance and patient advocacy.
Overview
20
20
years of professional experience
Work History
Utilization Review Nurse
Evolent Health
04.2013 - Current
- Performed reviews for inpatient stays (medical and mental health), surgeries and outpatient procedures for commercial/medicare/medicaid population.
- Utilizing medical guidelines through Interqual/MCG criteria (Milliman Care Guidelines) and/or CMS (Centers for Medicare/Medicaid Services) policies to determine appropriateness of services.
- Accurately identify discharge needs and performs reviews for patients requiring discharge planning to subacute nursing facilities, acute rehabilitation facilities, long term care facilities and assess needs for durable medical equipment.
- Identifying and referring to the Medical Director potential unnecessary services and quality care concerns.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Working closely with the “Evolent Team” identifies & assists patients that need additional support that could benefit from close monitoring from Evolents pharmacist, nutritionist or social worker.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
Utilization Review Registered Nurse
Active Health Management
12.2005 - 04.2013
- Maintained strict adherence to HIPAA regulations, safeguarding sensitive patient information throughout all aspects of the utilization review process.
- Collaborated with physicians to develop appropriate care plans based on utilization review findings that were both medically necessary and cost effective.
- Accurately reviews medical necessity utilizing Milliman criteria, for medical services requiring certification such as: admissions, length of stay, imaging studies, surgeries, durable medical equipment, medication and other out-patient procedures.
- Utilizes clinical guidelines and nursing judgement to make independent decisions on whether a patient meets guidelines for medical necessity reviews. Refers questionable cases (level of care, length of stay, potential non-certification decisions, issues of quality care and sentinel events) to the Medical Director.
- Screens, identifies and refers potential high risk/cost, catastrophic, long term chronic cases for Case Management assessment.
- Follows all policy and procedure for URAC requirements for timeliness or reviews and quality assurance.
- Primary trainer and resource utilization review nurse and often acted as fill in team leader.
Education
Bachelor of Science - Nursing
Georgetown University
Washington, DC05-1993
Skills
- InterQual criteria
- MCG (Milliman Criteria)
- CMS Policies (Centers for Medicare and Medicaid Services)
- Documentation and reporting
- Records analysis
Accomplishments
Veteran of the U.S. Airforce
Timeline
Utilization Review Nurse
Evolent Health
04.2013 - Current
Utilization Review Registered Nurse
Active Health Management
12.2005 - 04.2013
Bachelor of Science - Nursing
Georgetown University
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