LIA CLEMENS
McKinney,Texas
Summary
Results-oriented, highly motivated Utilization Review Nurse with experience in critical care nursing and case management in high-stress environments, providing staff training and counseling of patients and families. A dynamic communicator with the ability to interface at ease with all levels of the healthcare team. Knowledgeable in medical data gathering, analysis and authorization obtainment. Self-motivated professional promoting attention to detail and the drive to resolve issues effectively. Seeking the opportunity to join new organization in the role of Utilization Review Nurse.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Primary Nurse Case Admin I
Health Care Service Corporation: Blue Cross Blue Shield of Texas
Richardson, TX
09.2022 - Current
- Utilization review for managed care insurance company
- Evaluate medical guidelines and benefit coverage to determine appropriateness of services
- Directly responsible for reviewing pre-certification requests, performing inpatient initial admission and concurrent reviews, post-acute level of care reviews for LTAC, acute rehab and skilled nursing facilities; reviews for home health care, Durable Medical Equipment and home infusions based upon medical necessity per MCG specification and medical policy
- Refer high-risk cases which will benefit from case management services to the case management team
- Apply excellent ability to determine the medical necessity and appropriateness of care using established criteria
- Collaboration with internal medical directors, case managers, physician offices and supplier companies.
RN/Well-Being Health Advisor
Health Care Service Corporation: Blue Cross Blue Shield of Texas
Richardson, TX
10.2019 - 09.2022
- Focus on overall health of member by developing one-on-one relationship, help create health-related goals and track progress, handle complex needs as well as acute and chronic conditions and guide member through transition in care and education
- Exceeded expectations in each year with a performance rating of above expectations
- Precepted new clinical staff.
RN
Baylor Scott & White Medical Center Day Surgery
McKinney, TX
11.2018 - 10.2019
- Perform complete nursing care and assessments for patients in the pre and post-operative setting
- Complete post-procedural educational/follow-up phone calls.
RN
The Heart Hospital Baylor Plano Day Surgery
Plano, TX
10.2017 - 11.2018
- Collaborate with multidisciplinary healthcare teams to provide individualized and specialized pre-operative care to patients in accordance with physicians’ orders and hospital policies
- Managed care for post-procedural patients through discharge.
RN
Florida Hospital Imaging and IR
Orlando, FL
10.2013 - 05.2017
- Coordinated with multidisciplinary team to provide quality, evidence-based patient care by screening, prepping, and monitoring patients through all stages of procedures in both in and outpatient settings
- Provided patient education and follow-up care to ensure patient compliance and positive outcomes.
RN
Florida Hospital Multisystem PCU
Orlando, FL
02.2010 - 10.2013
RN
Florida Hospital PCU
Altamonte Springs, FL
10.2008 - 02.2010
RN
Gentiva Home Health Care
Winter Park, FL
05.2006 - 05.2007
RN
Firstat Nursing, Inc.
Winter Park, FL
02.2002 - 05.2006
Education
Bachelor of Science in Nursing -
Southern Adventist University
05.2000
Associates of Science in Nursing -
Southern Adventist University
05.1999
Skills
- Quality Improvement
- Healthcare Regulations
- Utilization Review
- Insurance Verification
- Medical Coding
- Documentation and Reporting
- HIPAA Compliance
- Medical Recordkeeping
- Training Staff
- ICD-10
- Microsoft Office
- Diagnostic Test Evaluations
- Medical Procedure Preparation
- Policy Knowledge
- Regulatory Compliance
- Data Analysis
- Client Needs Assessments
- Windows Operating Systems
- Software Applications
- Community Resources
- Care Coordination
- Interdisciplinary Collaboration
- RN Case Management
- Disease Management
Certification
- Texas compact RN license, Oregon RN license, Massachusets RN license, Alaska RN license
Timeline
Primary Nurse Case Admin I
Health Care Service Corporation: Blue Cross Blue Shield of Texas
09.2022 - Current
RN/Well-Being Health Advisor
Health Care Service Corporation: Blue Cross Blue Shield of Texas
10.2019 - 09.2022
RN
Baylor Scott & White Medical Center Day Surgery
11.2018 - 10.2019
RN
The Heart Hospital Baylor Plano Day Surgery
10.2017 - 11.2018
RN
Florida Hospital Imaging and IR
10.2013 - 05.2017
RN
Florida Hospital Multisystem PCU
02.2010 - 10.2013
RN
Florida Hospital PCU
10.2008 - 02.2010
RN
Gentiva Home Health Care
05.2006 - 05.2007
RN
Firstat Nursing, Inc.
02.2002 - 05.2006
Bachelor of Science in Nursing -
Southern Adventist University
Associates of Science in Nursing -
Southern Adventist University
- Texas compact RN license, Oregon RN license, Massachusets RN license, Alaska RN license
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