Lori Nau
St. Clairsville,OH
Summary
Seasoned professional with extensive experience driving positive patient outcomes through comprehensive oversight of the clinical care review process. Demonstrated excellence in developing and administering policies and procedures for utilization control of inpatient and outside referral services countywide; monitoring referral patterns and making recommendations; assisting in development and implementation of procedures to track and trend specialty. Conducted utilization reviews, demonstrating a strong attention to detail and comprehensive understanding of the review process. Registered Nurse (RN) with a wealth of expertise in utilization review and leadership roles within pediatrics, adult medical/surgical, and the health insurance industry. Proficient in reviewing medical necessity for ongoing client care, ensuring appropriate levels of care are provided and connecting clients to higher levels of care when necessary. Skilled in leveraging technology and leading initiatives to effectively manage and achieve key performance indicators (KPIs). Proven track record of identifying data-driven needs and opportunities for enhancing clinical care review processes on a large scale. Successfully led teams of 10-15 staff members, providing guidance, support, and fostering a collaborative work environment.
Overview
1
1
Certification
25
25
years of professional experience
Work History
Auditor, Clinical Validation
Cotiviti
South Jordan, Utah
07.2023 - Current
- Audited medical records for short stay inpatient admission payment accuracy and readmissions.
Manager, Integrated Care
Highmark, Inc.
Pittsburgh, PA
10.2018 - 04.2023
- Tasked with overseeing a department that experienced an influx of team members from various parts of the organization due to manager attrition, successfully combining all areas into a unified team with diverse skill sets.
- Recognized as the manager of the team with the highest employee satisfaction, as indicated by the core behaviors survey.
Inpatient Care Manager
United Healthcare
Pittsburgh, PA
01.2016 - 10.2018
- Acted as the primary contact for assigned hospitals, handling all aspects of utilization review efficiently and effectively. Managed the care of 20-25 patients on a daily basis, ensuring their needs were met and coordinating with providers.
- Conducted 15-20 inpatient case reviews daily, meticulously evaluating each case to ensure appropriate care and utilization of resources.
- Developed strong relationships with healthcare providers, fostering effective communication and collaboration to deliver optimal patient care.
Clinical Liaison
Acuity Specialty Hospital
Steubenville, OH
02.2015 - 01.2016
- Took on the responsibility of advocating for patients during the pre-admission process, collaborating with clinical teams and groups to assess the medical needs and conditions of both current and prospective patients. Worked collaboratively with various departments and facilities, fostering seamless coordination and communication to facilitate optimal patient care.
- As a patient and provider-facing liaison, effectively coordinated the review of medical records and facilitated the admission process to Long Term Acute Care, ensuring appropriate and timely care for 1-5 patients on a daily basis.
- Fostered strong relationships throughout the facility, serving as a valuable hospital resource and establishing a reputation for achieving impactful results.
Utilization Review Nurse
The Health Plan of the Upper Ohio Valley
St. Clairsville, OH
- 02.2015
- Hand-selected as the lead Utilization Review Nurse to provide support and guidance to the nurse review team members. Conducted 25-30 daily admission, concurrent, and retrospective clinical reviews, utilizing InterQual criteria to assess the severity of illness and intensity of service. Supervised a team of 10 in-house and on-site employees, overseeing their performance and ensuring adherence to quality standards.
- Recognized for successful implementation of discharge planning strategies and ensuring appropriate level of care transfers.
- Completed 25-30 inpatient case reviews on a daily basis, demonstrating strong clinical expertise.
- Assumed supervisor duties for a team of 10 nurse reviewers both in the office and on-site, effectively managing their workload and providing leadership and guidance.
Education
Associate Degree - Applied Science in Registered Nursing
Belmont Technical College
St. Clairsville, OHSkills
- Utilization Review & Management
- Clinical Care Management
- Leadership & Team Management
- Discharge Planning
- Decision-making
- Clear communication
- InterQual criteria
- Documentation and reporting
- Inpatient care
- Managed care
- Patient care assessment
- Teamwork
- Problem-solving
- Multitasking
- Excellent communication
- Critical thinking
Certification
- Licensed RN multi-state
Timeline
Auditor, Clinical Validation
Cotiviti
07.2023 - Current
Manager, Integrated Care
Highmark, Inc.
10.2018 - 04.2023
Inpatient Care Manager
United Healthcare
01.2016 - 10.2018
Clinical Liaison
Acuity Specialty Hospital
02.2015 - 01.2016
Utilization Review Nurse
The Health Plan of the Upper Ohio Valley
- 02.2015
Associate Degree - Applied Science in Registered Nursing
Belmont Technical College