Lendi Haley

Utilization Review Nurse

Sentara

11.2014 - Current

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.
Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Performed prior authorization review of services requiring notification.
Mitigated potential legal issues related to improper admission or discharge decisions by consulting with physicians regarding complex cases that required further clarification.
Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
Submitted cases for criteria failures and helped facilitate resolutions and approvals.
Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
Increased staff efficiency by providing ongoing education on proper documentation techniques necessary for accurate claims processing.
Supervised and maintained all utilization review documentation through Interqual and Milliman.
Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
Obtained authorizations from multiple insurance carriers for various levels of care.
Enhanced patient satisfaction by collaborating with interdisciplinary teams to develop individualized care plans, ensuring appropriate level of care.
Promoted positive outcomes with proactive assessment of patients'' needs and development of targeted interventions to address identified barriers to recovery.
Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
Devise or identify solutions for irregular requests and issues.
Supported data-driven decision-making by regularly analyzing trends in resource utilization, identifying opportunities for improvement, and implementing best practices.
Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
Performed admission reviews based for medical necessity based upon Medical Director specification.
Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
Supported organizational growth and development through effective collaboration with interdisciplinary teams focused on improving the quality, safety, and efficiency of healthcare delivery.
Collaborated with physicians to clarify treatment plans, ensuring alignment with evidence-based practices.
Negotiated care options with insurance carriers to secure coverage for recommended treatments.
Ensured timely patient discharges by coordinating with healthcare teams, optimizing bed availability.
Facilitated compliance with federal and state regulations, maintaining high standards of healthcare delivery.
Monitored patient care outcomes to identify trends and areas for improvement.
Implemented continuous improvement program for utilization review process, leading to better healthcare management.
Conducted thorough evaluations of medical necessity for procedures, leading to optimal resource utilization.
Enhanced team efficiency with development of streamlined review processes.
Led interdisciplinary team meetings to discuss complex cases, facilitating comprehensive care planning.
Resolved insurance reimbursement issues, reducing financial barriers to necessary treatments.
Developed patient care plans in consultation with healthcare professionals, ensuring multidisciplinary approach.
Supported healthcare equity by identifying and addressing gaps in care for underserved populations.
Improved patient outcomes by meticulously reviewing patient records to ensure appropriate care levels.
Conducted training sessions for new nurses, enhancing team's review capabilities.
Increased patient satisfaction by advocating for necessary patient care and services.
Promoted patient education by providing resources and information on treatment options and healthcare rights.
Enhanced patient care coordination by effectively communicating review outcomes to healthcare teams.
Assessed patient feedback to inform quality improvement initiatives.
Reduced unnecessary medical costs, ensuring treatments met established medical guidelines and policies.
Streamlined communication between healthcare providers and insurance companies, improving claim processing times.
Communicated with healthcare team members to plan, implement and enhance treatment strategies.
Evaluated patient histories, complaints, and current symptoms.
Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
Recorded details regarding therapies to keep patient charts updated.
Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Equipped patients with tools and knowledge needed for speedy and sustained recovery.
Investigated and resolved issues affecting hospital operations and patient care.
Managed patients recovering from medical or surgical procedures.
Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
Implemented care plans for patient treatment after assessing physician medical regimens.
Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
Provided skilled, timely and level-headed emergency response to critically-ill patients.
Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
Performed triage on incoming patients and determined severity of injuries and illnesses.
Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
Educated family members and caregivers on patient care instructions.
Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
Worked with healthcare team to develop new dialysis treatment flow sheet and other log forms, improving clinical documentation and accountability.
Monitored patient reactions after administering medications and IV therapies.
Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.

Summary

Overview

Work History

Utilization Review Nurse

Healthcare/Business Analyst Intern

Utilization Review Nurse

Education

Master of Science in Marketing - Marketing Analytics Specialization

Bachelor of Science in Business Administration - Operations, Logistics, and Supply Chain Management

LPN, Licensed - undefined

Skills

Certification

Timeline

Healthcare/Business Analyst Intern

Utilization Review Nurse

Utilization Review Nurse

LPN, Licensed - undefined

Master of Science in Marketing - Marketing Analytics Specialization

Bachelor of Science in Business Administration - Operations, Logistics, and Supply Chain Management

Similar Profiles

Matthew RawlsMatthew Rawls

Quennisha MartinQuennisha Martin

AMY SIMMONSAMY SIMMONS

Cameron SpanglerCameron Spangler

Feroz SafiFeroz Safi