Lisa Bourgeois
Utilization Review Registered Nurse
Naples,FL
Summary
Utilization Management Nurse with extensive experience at Oscar Health, skilled in applying clinical judgment and medical terminology to improve service appropriateness. Demonstrated success in documentation and reporting, ensuring compliance and streamlining review processes. Strong interpersonal communication abilities enhance collaboration with multidisciplinary teams, leading to optimized patient care outcomes.
Overview
44
44
years of professional experience
Work History
Utilization Management Nurse
Oscar Health
Naples, FL
12.2021 - 10.2025
- Evaluated medical guidelines and benefit coverage to determine service appropriateness.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Referred cases to secondary review for failure to meet criteria.
Clinical Documentation Specialist
Ensemble
Naples, FL
04.2021 - 10.2021
- Collaborated with physicians, nurses, and other caregivers to convey the significance of precise and clear documentation.
- Informed physicians regarding absent or ambiguous health record documentation, requesting further information for clarification purposes.
- Maintained a robust understanding of medical terminology, diseases, conditions, and procedures.
Utilization Review Nurse
Aetna
Naples, FL
11.2020 - 03.2021
- Conducted prior authorization reviews of services requiring notification.
- Reviewed clinical documentation employing MCG criteria for commercial insurance.
Registered Nurse
SSM Rehabilitation Hospital
Richmond Heights
08.2020 - 11.2020
- Conducted thorough patient assessments to identify health issues and develop appropriate nursing interventions.
- Participated in multidisciplinary meetings to discuss patient care strategies.
Utilization Review Registered Nurse
Mercy Utilization Review Department
St. Louis
01.2020 - 06.2020
- Performed pre-certification, concurrent, and retrospective reviews of inpatient and outpatient services.
- Referred cases to secondary review for failure to meet criteria.
Utilization Review Nurse
Aetna
Hazelwood
12.2014 - 11.2019
- Developed and maintained comprehensive knowledge of insurance policies, clinical guidelines, and regulatory requirements to enhance review processes.
- Reviewed and interpreted complex clinical data to make informed decisions about service authorizations and denials.
- Conducted training sessions for nursing staff on utilization review protocols and documentation standards to improve compliance.
Agency Registered Nurse
Grace Staffing, First Call, MSN
Columbia
04.2006 - 07.2012
- Conducted thorough health assessments to identify patient needs and develop appropriate interventions in the ICU.
- Collaborated with physicians to promptly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
RN Case Manager
Missouri River - Walgreens Hospice
Columbia
01.2007 - 05.2009
- Delivered comprehensive care to home health patients, including physical assessments, medication management, and chronic disease oversight.
- Conducted ongoing mental health assessments, collaborating with a multidisciplinary team to develop, implement, manage, and modify individualized care plans.
Staff Registered Nurse, ICU
University Hospital And Clinics
Columbia
12.1991 - 07.2006
- Conducted patient assessments and diagnostic tests to provide physicians with critical health information, essential for formulating focused treatment plans and managing ongoing care.
- Reacted to emergency situations with efficiency, expertise, and levelheadedness to deliver optimal care and life-saving interventions.
LPN Floor Nurse / RN Cardiac Stepdown Nurse
Phelps County Regional Medical Center
Rolla, MO
07.1981 - 12.1991
- Collaborated with healthcare team members to assess, implement, and evaluate nursing care plans.
- Evaluated cardiac status, alerting physicians to any changes in patient conditions, and assisted with medical procedures.
Education
Associate of Science - Nursing
Park University
Kansas City06.1989
Licensed Practical Nurse - Nursing
Waynesville Career Center
Waynesville06.1982
Skills
- Documentation and reporting
- Utilization review
- Medical terminology
- Clinical experience and judgment
- Interpersonal communication
- Medical ethics
Timeline
Utilization Management Nurse
Oscar Health
12.2021 - 10.2025
Clinical Documentation Specialist
Ensemble
04.2021 - 10.2021
Utilization Review Nurse
Aetna
11.2020 - 03.2021
Registered Nurse
SSM Rehabilitation Hospital
08.2020 - 11.2020
Utilization Review Registered Nurse
Mercy Utilization Review Department
01.2020 - 06.2020
Utilization Review Nurse
Aetna
12.2014 - 11.2019
RN Case Manager
Missouri River - Walgreens Hospice
01.2007 - 05.2009
Agency Registered Nurse
Grace Staffing, First Call, MSN
04.2006 - 07.2012
Staff Registered Nurse, ICU
University Hospital And Clinics
12.1991 - 07.2006
LPN Floor Nurse / RN Cardiac Stepdown Nurse
Phelps County Regional Medical Center
07.1981 - 12.1991
Associate of Science - Nursing
Park University
Licensed Practical Nurse - Nursing
Waynesville Career Center