LaNora Gray
Clarksville,TN
Summary
Dedicated and compassionate healthcare leader with over ten years of functional case management and utilization review experience. Enacts a solid, collaborative approach across the care continuum and manages workflow to support dynamic teams. Spearheaded operational effectiveness and efficiencies to develop quality improvement activities and achieve financial goals.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Director of Utilization Review: Case Management
Community Health Systems (CHS)
09.2022 - Current
- Provide guidance for strategic direction, management, improvement, and maintenance of the Utilization Review team
- Develop policies, procedures, and workflows that incorporate best practices and ensure effective utilization reviews
- Collaborate with Physician Advisors, Revenue Cycle Leaders, Utilization Review Business Performance Director, and Case Management leadership to design and implement denial prevention strategies across the regions
- Evaluate effectiveness of utilization management through analysis of defined metrics and recommend enhancements and/or improvements to facilitate consistent, cost-effective and proactive utilization management
- Maintain working knowledge of payor standards for utilization review
- Ensure compliance in both government and contractual guidelines
- Provide mentoring and coaching to direct reports to build and strengthen Utilization Management effectiveness
- Establish/maintain working relationships with all functional areas to ensure thorough follow-up and completion of projects and issues
- Help in developing, analyzing, and maintaining key performance indicators that impact staffing levels, quality of services, revenues, or expenses.
Utilization Review Nurse: Utilization Management
Oscar Health Insurance Company
03.2022 - 08.2022
- Responsible for utilization management and utilization review for prospective (prior authorization) reviews
- Performed reviews of services, and determine medical appropriateness outpatient services following evaluation of medical guidelines and benefit determination
- Obtained the information necessary (via telephone and fax) to assess a member's clinical condition, and applied the appropriate evidence-based guidelines and medical policies to determine medical necessity which could include Oscar Clinical Guidelines, Milliman Care Guidelines, Hayes, UpToDate, etc
- Met required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
- Followed documentation guidelines for clear and concise decision-making within our utilization review tracking platform.
Director of Standards and Process Validation Team: Corporate Case Management
Hospital Corporation of America (HCA) Corporate Office
05.2016 - 03.2022
- Assisted with developing standard review processes and tools for case management and utilization review services, resulting in moving patients through the continuum of care efficiently and improving the process of obtaining authorization for services rendered to patients
- Analyzed denials and identified process improvement opportunities
- Supported utilization review services related denial mitigation strategies
- Developed and presented reports to the executive leadership team
- Collaborated with division leadership to solve problems and mitigate risks
- Maintained a strong relationship with payers
- Assisted external counsel with the review of medical claims in reimbursement disputes with health insurance payers
- Worked with information technology on developing technology solutions for utilization review services
- Served as business lead for developing Utilization Review Quality Assurance Program
- Served as the business lead for the Concurrent Denials Team
- Assisted with the development of the centralized denials team
- Managed the day-to-day operations of the denials team, which improved the number of denied accounts that were appealed and increased the denial overturn rate.
Utilization Review Specialist and Team Lead: Utilization Management
Vanderbilt University Medical Center
03.2015 - 05.2017
- Conducted admission and concurrent reviews to ensure an appropriate clinical level of care and documentation demonstrate medical necessity
- Submitted clinical information to external payers to secure proper authorization and ensure that prompt notification of any denial is communicated to the Denials and Appeals Coordinator
- Collaborated with Providers, the Business office, Case Management, and Physician Advisors to improve the utilization review process and throughput
- Documented patient case information within the database system
- Ensured timely and accurate reviews that result in medically necessary, appropriate, efficient, and cost-effective health services
- Monitored length of stay, observation cases, delays in discharges or care, reimbursement and financial indicators in order to recommend and implement improvement strategies
- Ensured that all utilization management contract requirements were met
- Monitored team’s performance and provided feedback and guidance to staff
- Tracked and analyzed data generated through internal and external sources
- Established the utilization management department goals in collaboration with the Medical Director and the executive leadership team
- Developed policies and procedures, outlining effective utilization review practices
- Managed the clinical appeals process
- Assured that all appeals were filed timely
- Assisted with developing the annual operating budget for the utilization management department.
Case Manager: Case Management Department
Gateway Medical Center
10.2012 - 02.2015
- Performed utilization review services
- Coordinated post-acute services for patients
- Educated patients on disease management, community resources, and follow up
- Collaborated with a multidisciplinary team to help reduce hospital length of stay and readmissions
- Performed continuous assessments and evaluations to ensure patient was progressing towards desired outcomes
- Identified and resolved barriers that hindered effective patient care
- Responsible for drafting, finalizing, and submitting appeal letters to reverse a denial.
Education
Leadership Excellence Program Class of 2021 -
HCA Leadership Institute
Nashville, TNLeadership in Action Training -
HCA Leadership Institute Academy
Nashville, TN01.2019
Master of Science in Nursing -
Western Governors University
Salt Lake City, UT01.2018
Bachelor of Science in Nursing -
Middle Tennessee State University
Murfreesboro, TN01.2005
Skills
- Strategic Planning
- Data Analysis
- Medicare Compliance
- Budget Planning
- Training and Mentoring
- Process Improvement
- Utilization Management
- Organizational Goal Development
- Quality Management
- Resource Monitoring
Certification
Registered Nurse (RN), Tennessee
Affiliations
- McNair Scholar: Undergraduate Research Program, 2004
- Sigma Theta Tau International, Honor Society of Nursing Member, 2005
Publications
Managing the Silent Killer: Hypertension, Gray, L., Prevost, S., 2006, McNair Research Review Magazine, IV, 85-90
Timeline
Director of Utilization Review: Case Management
Community Health Systems (CHS)
09.2022 - Current
Utilization Review Nurse: Utilization Management
Oscar Health Insurance Company
03.2022 - 08.2022
Director of Standards and Process Validation Team: Corporate Case Management
Hospital Corporation of America (HCA) Corporate Office
05.2016 - 03.2022
Utilization Review Specialist and Team Lead: Utilization Management
Vanderbilt University Medical Center
03.2015 - 05.2017
Case Manager: Case Management Department
Gateway Medical Center
10.2012 - 02.2015
Leadership Excellence Program Class of 2021 -
HCA Leadership Institute
Leadership in Action Training -
HCA Leadership Institute Academy
Master of Science in Nursing -
Western Governors University
Bachelor of Science in Nursing -
Middle Tennessee State University
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