LaTonya Clarke, LPN
Summary
Experienced Utilization Management Review Nurse with strong critical thinking and decision-making skills. Focused driven to exceed company goals and expectations. Excellent at multitasking and working under pressure.
Overview
17
17
years of professional experience
Work History
Clinical Operations Analyst/Authorization Coordinator
Sentara Health Plan/Virginia Premier Health Plan
06.2018 - Current
- Validate clinical dashboard data reports such as CCC+, Grievances and Appeals, Annual Measure LTSS Report, Authorization Term/No Waiver report, and Missed deferred print report.
- Managed Single Case Agreement requests for out-of-network providers.
- Review and approve all administrative and medical necessity denial letters, ensuring NCQA compliance.
- Assist in creating policies, procedures, and job aids for the clinical review team.
- Participated in State Fair Appeal hearings for all LTSS authorization requests.
- Reviewed and adjusted appeal authorizations according to the Medical Director's recommendations on appeal.
- Conducted regular monthly review audits for the LTSS Clinical Review Team.
- Managed multiple projects simultaneously, delivering results within tight deadlines while maintaining high-quality standards.
Utilization Review Nurse Supervisor
KEPRO
11.2009 - 12.2017
- Review and interpret patient records against criteria to determine medical necessity and appropriateness of care.
- Conducted monthly reviewer audits for all waiver reviewers.
- Created monthly IRR (Interrater Reliability) for the waiver clinical reviewers.
- Trained all new waiver staff to waiver services.
- Attended all formal & informal hearings at DMAS.
- Scheduled and hosted monthly waiver team meetings with reviewers.
- The direct point of contact for DMAS regarding waiver services.
- Reviewed and responded to DMAS contract monitor monthly audit.
- Collaborated with DMAS contract monitors biweekly to discuss waiver issues, concerns, and upcoming changes.
- Reviewed administrative denials referred by the clinical reviewers to ensure denial complies with DMAS criteria.
- Attended monthly QI meetings with the leadership team & DMAS.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
Licensed Practical Nurse (Charge Nurse)
Beaufont Rehabilitation Healthcare Center
09.2008 - 11.2009
- Managed patient care through closely monitoring respiration, blood pressure, and blood glucose levels.
- Administer prescribed medications or start intravenous fluids, noting times and amounts on patients' charts.
- Evaluate nursing intervention outcomes, conferring with other healthcare team members as necessary.
- Oversee patient care for the entire unit by communicating with nurses and physicians, checking and entering orders on charts to verify accuracy, and assisting with making daily assignments for the unit to ensure a safe patient-to-nurse ratio.
- Assist with admissions, appointments, transfers, and discharges.
- Provided wound care dressing changes, IV therapy administration, catheter insertion, and other routine nursing procedures.
Education
Practical Nursing Diploma -
Richmond School Of Health And Technology
Henrico, VA05-2008
Skills
- Clinical Utilization Review
- Proficient in Microsoft Word
- Excel Proficiency
- PowerPoint Proficiency
- Critical Thinker
- Effective Communication
- Detail Oriented
- Quick Learner
- Self-Starter
- Reliable Team Player
Timeline
Clinical Operations Analyst/Authorization Coordinator
Sentara Health Plan/Virginia Premier Health Plan
06.2018 - Current
Utilization Review Nurse Supervisor
KEPRO
11.2009 - 12.2017
Licensed Practical Nurse (Charge Nurse)
Beaufont Rehabilitation Healthcare Center
09.2008 - 11.2009
Practical Nursing Diploma -
Richmond School Of Health And Technology
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