Latoria Jackson

Multi-state licensed Nurse Consultant with over 20 years of experience in Utilization Review, Case Management, HEDIS, Quality Auditing, and Medical Bill Review. Expert in medical necessity determinations, pre-authorization, and regulatory compliance with deep knowledge of CMS, NCQA, URAC, and state guidelines. Skilled in managing care for Medicare Advantage, Medicaid, Special Needs, and Dual-Eligible populations, performing Health Risk Assessments (HRA), and ensuring optimal care coordination. Proficient in InterQual and Milliman criteria with strong background in ICD-10, CPT, HCPCS, and E&M coding.

• Florida Multi-State Compact Nurse Licensure, #PN5151340
• Nevada Nurse Licensure, #873921
• California Nurse Licensure, #742532
• Assisted Living Facility Administrator #171242209
• Florida 6-20 All Lines Adjuster, #W227471
• Florida 215 Life, Health, Annuities, #W227471

Utilization Review, Prior Authorization, Appeals, Concurrent Review, Retrospective Review, Case Management, Chronic Care Management (CCM), Transitional Care, Disease Management, Special Needs Plans (SNP), Dual-Eligible Special Needs Plans (DSNP), Medicare Advantage (MA), Medicaid, Commercial Insurance, Risk Adjustment, HEDIS, STAR Ratings, Quality Improvement, Quality Auditing, Data Abstraction, Population Health, InterQual Criteria, Milliman Care Guidelines, Evidence-Based Guidelines, ICD-10, ICD-9, CPT, HCPCS, E&M Coding, Medical Necessity Determinations, Benefit Interpretation, Contract Review, Provider Education, HIPAA Compliance, NCQA Standards, URAC Accreditation, CMS Regulations, Appeals & Denials Management, Medical Claims Review, Workers’ Compensation, Liability Claims Review, Special Investigations Unit (SIU), Epic, EZ-CARE, EZ-CAP, PointClickCare, Practice Fusion, Cozeva, Clinical Repository, Microsoft Office Suite, Google Workspace, Zoom, Webex, Genesys, ICUE, HEDIS Software, EMR/EHR Platforms, Telehealth Platforms, Health Risk Assessments (HRA), Medication Therapy Management (MTM), Wound Care, Diabetes Management, Phlebotomy, PT/INR Monitoring, Patient Education, Care Plan Development, Specialty Referrals, Provider Collaboration, Peer-to-Peer Reviews, Community Resource Coordination, Home Health Services