Kimberly Semerad
Johnsonville,NY
Summary
Registered Nurse experienced in leading utilization review teams to optimize healthcare delivery and resource management. Proven ability to leverage effective communication and conflict resolution skills to drive team success and achieve organizational goals. Knowledge of strategic planning and employee development to enhance productivity and boost team morale. Recognized for collaborative leadership and adaptability in fast-paced healthcare environments, ensuring team cohesion and consistent, high-quality results.
Overview
17
17
years of professional experience
Work History
Supervisor, Utilization Review
Capital District Physicians Health Plan
05.2022 - Current
- Led team of utilization review nurses, overseeing execution of daily prior authorization activities for inpatient level of care, post-acute care, concurrent reviews, and hospital readmissions. Facilitating appropriate and timely review of healthcare services to optimize member outcomes. Managed evaluations of out-of-network requests to ensure compliance with policies.
- Participate in regulatory audits, oversee quality review processes and develop new quality initiatives to facilitate continued process improvement.
- Ensured adherence to and execution of all departmental policies and procedures to enhance operational efficiency.
- Oversaw orientation and training initiatives for new personnel. Evaluated staff development requirements and collaborated with management on educational planning.
- Monitored monthly performance metrics to evaluate staff effectiveness and conducted assessments, implementing disciplinary actions when required.
Team Lead, Hospital to Home Programs
Capital District Physicians Health Plan
06.2018 - 05.2022
- Oversaw daily quality assurance and compliance monitoring for departmental operations. Conducted comprehensive review and analysis of medical necessity and contractual information to ensure compliance with regulatory standards.
- Assisted department in meeting regulatory reporting requirements through data trending and analysis. Supported preparation for regulatory audits and participated in audit processes along with monthly, quarterly, and annual reviews.
- Assisted in developing and executing processes to improve operational efficiency and promote consistency in application and decision-making. Created educational tools to facilitate new employee orientation and support staff development initiatives.
- Analyzed staffing needs in partnership with leadership team to streamline assignments and boost departmental productivity.
Inpatient Care Coordinator
Samaritan Hospital
11.2013 - 06.2018
- Conducted concurrent and retrospective evaluations for inpatient hospital and skilled nursing facility admissions based on medical necessity. Assisted in the referral of relevant cases to medical directors for assessment of potential denials.
- Ensured compliance with regulatory determination and notification turnaround times across various lines of business and review types.
- Facilitated communication between hospital case management teams and members to enhance community resource awareness and discharge strategies. Coordinated referrals for members to internal case management services as needed.
- Analyzed and interpreted benefit plans, contracts, and provider networks to facilitate compliance with resource coordination procedures.
Registered Nurse, Progressive Care Unit
Samaritan Hospital
05.2009 - 11.2013
- Conducted thorough assessments of patients and recorded accurate findings to uphold high standards of care. Administered medications and monitored patient responses in high-acuity setting.
- Supported patients in achieving independence through the establishment of care goals. Educated patients and families on understanding medical conditions, medications, and essential self-care skills. Provided answers to inquiries regarding treatment and care processes.
- Implemented policies and procedures to maintain strict compliance with federal HIPAA standards.
- Engaged in continuing education courses and workshops to enhance professional knowledge.
Education
Bachelor of Science - Nursing
SUNY Polytechnic Institute (SUNY IT)
Utica, NY05-2014
Associates Degree - Nursing
Samaritan Hospital School of Nursing
Troy, NY05-2009
Skills
- Registered Professional Nurse
- Case Manager Certification (CCM)
- Proficient in Microsoft Office Suite
- Staff management
- Training and mentoring
- Goal oriented
- Employee motivation
- Process monitoring and improvement
Timeline
Supervisor, Utilization Review
Capital District Physicians Health Plan
05.2022 - Current
Team Lead, Hospital to Home Programs
Capital District Physicians Health Plan
06.2018 - 05.2022
Inpatient Care Coordinator
Samaritan Hospital
11.2013 - 06.2018
Registered Nurse, Progressive Care Unit
Samaritan Hospital
05.2009 - 11.2013
Associates Degree - Nursing
Samaritan Hospital School of Nursing
Bachelor of Science - Nursing
SUNY Polytechnic Institute (SUNY IT)