Lana Turner
Prince Frederick,MD
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
14
14
years of professional experience
Work History
Utilization Review Nurse/RN Case Manager
Evolent Health
Arlington,VA
07.2012 - 01.2026
- Performed reviews for inpatient admissions, continued stay, post acute, surgeries and outpatient procedures for commercial/medicare/medicaid populations.
- Collaborated with healthcare teams to facilitate effective patient care planning and resource allocation.
- Utilizing medical guidelines through InterQual/MCG criteria (Milliman care guidelines) and/or CMS (Center 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.
- Identify and referring to the Medical Directors potential unnecessary services and quality care concerns.
- Maintain professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- 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.
- Working closely with the Evolent team to identify and assist patients that need additional support and that could benefit from Evolents pharmacist, nutritionist or social worker.
- Conducted training sessions for nursing staff on utilization review protocols and best practices.
- Mentored junior nurses in case analysis, promoting professional development and knowledge sharing.
Education
Bachelor of Science - Nursing
University of New Brunswick
Fredericton, New Brunswick05.1988
Skills
- InterQual criteria (Certified as an instructor)
- Documentation and reporting
- Utilization review
- Records analysis
- Milliman guidelines
- Adaptability and flexibility
- Problem-solving
- Discharge planning
- CMS Policies
- Software proficient
- Clinical knowledge
- Payor and regulatory understanding
Timeline
Utilization Review Nurse/RN Case Manager
Evolent Health
07.2012 - 01.2026
Bachelor of Science - Nursing
University of New Brunswick