LORI SHEPHERD LPN/LVN
Utilization Review and Appeals Nurse Manager
Casa Grande,AZ
Summary
Experienced, team oriented professional proudly offering more than 30 years of expertise in nursing field. Well-rounded and personable Utilization Review Nurse considered critical thinker and problem-solver with thorough understanding of Medicare guidelines. Served as Manager of Utilization Review and appeals team, Director of Case management, Supervisor for the Prior Authorization/Utilization Management and Notice of Action teams with an excellent understanding of CMS/ Medicare laws and regulations. Adept in appeals , grievances and state and federal audit situations. Proficiency in the identification and application of medical necessity standards for utilization review, prior authorization and retrospective review. Successful application of Milliman Care Guidelines, InterQual criteria, Medicare and State Medicaid guidelines.
Overview
30
30
years of professional experience
Work History
Utilization Review Nurse Manager
Oscar Health
Tempe, Arizona
07.2018 - Current
- Served as subject matter resource, providing information related to Medicare , Health Exchange and Commercial Plans .
- Effectively supervised staff of 12 personnel by implementing company policies, protocols, work rules and disciplinary action.
- Established team priorities, maintained schedules and monitored performance.
- Facilitated workgroup meetings with department stake holders to find effective solutions to issues.
- Supported and performed clinical appeals and grievances for Medicare Advantage Members in New York, Texas, Florida
- Utilizes Medicare National and Local Coverage Determinations (NCD, LCD),Oscar Clinical Guidelines, Milliman Care guidelines, Up to Date and Hayes as well as other established criteria for guidance standards for appropriate determination of inpatient event/stay or outpatient care
- Conducts ongoing review by reviewing inpatient criteria as appropriate and utilizing peer review as necessary
- Communicates potential denials for continued stay with Medical Director(s) for determination
- Completes documentation in electronic medical record and claims system using approved templates and maintaining documentation standards
- Maintains professional demeanor in all dealings with providers and co-workers.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
Director Case
La Estancia Nursing & Rehabilitation
Phoenix, Arizona
11.2016 - 07.2018
- Responsible for facilitating, reviewing and preparing interdisciplinary plans as well as assuring comprehensive progress reports are completed and provided to multiple payers as required; Also serves as liaison between patient, physician, care team members, and payer, by monitoring and communicating patient's progress and cost evaluation
- Coordinates treatment plans and discharge expectations
- Provides information to patients and families regarding health plan benefits, community resources, specialty referrals and other related issues
- Extensive experience with managed care, Medicare, Medicaid, long term care, workers' compensation, insurance, and commercial insurance
- Ability to negotiate coverage and provide complete and timely case management
- Utilizing knowledge of prior authorization guidelines along with regulation criteria for both Medicare and Medicaid using CMS, InterQual and Milliman Care Guidelines
- Strong oral, written, and organizational communication skills.
Utilization Review Nurse
Conifer Health/ Phoenix Health Plan
Phoenix, Arizona
10.2015 - 11.2016
- Performs utilization review of all inpatient or outpatient admissions and initiates discharge planning in timely manner
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services
- Utilizes clinical skills, chart review, physician communication, and Milliman Care guidelines as well as InterQual standards for approval of inpatient event/stay
- Conducts ongoing review by reviewing inpatients as appropriate and utilizing peer review as necessary
- Communicates potential denials for continued stay with Medical Director(s) for determination
- Facilitates member’s transfers within contract facilities for ongoing inpatient stays
- Completes documentation in electronic medical record and claims system
- Maintains professional demeanor in all dealings with providers and co-workers
- Notification to facility of denial
- Upon discharge, process member transitions to safe, appropriate environment with effective continuing care.
Prior Authorization Supervisor
Health Choice
Phoenix, Arizona
04.2015 - 10.2015
- Coordination of activities of Prior Authorization Department related to authorization of medical services for Health Choice members across eight lines of business
- Monitors all authorization processes for meeting coordination of care, timeliness standards, and cost effectiveness
- Assures department efficiency and effectiveness of staff .Ensures staff meets production goals and standards of at least 90% monthly
- Provide staff education in order to train, orient, mentor and serve as role model for expectations
- Demonstrates extensive knowledge of prior authorization guidelines, regulation criteria for both Medicare and Medicaid lines of business
- Demonstrates proficiency in InterQual and Milliman Care Guidelines
- Provides critical thinking, analytical, communication and problem solving skills creating dynamic team atmosphere.
- Identified issues, analyzed information and provided solutions to problems
- Proved successful working within tight deadlines and fast-paced atmosphere
Nurse Auditor, Utilization Review
Mercy Care Plan
Phoenix, Arizona
09.2008 - 04.2015
- Lead nurse auditor on Notice of Action Team
- Authorization/Utilization Management Primary Nurse auditor for Utilization Management (UM) department for Medicare Advantage and Medicaid insurance plan
- Extensive knowledge in CMS/ Medicare and AHCCCS laws and policies that govern PA and UM process for inpatient and outpatient services
- Interacts with medical directors, members and staff from other areas of company and AHCCCS and CMS in order to have full understanding of requirements of PA/UM while also instructing on these requirements
- Utilized this knowledge to assist and manage determinations that are in member’s best interest while meeting requirements of governing bodies and being cost effective
- Subject matter expert in Medicare criteria as it applies to plan determinations for prior authorizations Assisted Medical Director in researching Medicare as well as Medicaid criteria to be appropriately applied to precertification process
- Assisted Medical Directors in gathering information and determining appropriate clinical criteria used in pending appeals requests
- Prior Authorization Nurse - determining medical necessity for requested service using appropriate clinical criteria for all lines of business
- Maintain high standards in all aspects of Med Management / Prior authorization work product and processes
- Determines appropriate coverage using Milliman Guidelines
- Achieved and maintains
- 100% accuracy in annual Milliman Guideline training.
Nurse, Team Lead
United Health Group
Phoenix, Arizona
06.2006 - 09.2008
- Utilization Management- Prior Authorization, , maintained team metrics tracking and reporting
- Subject matter expert in Medicare criteria as it applied to plan determinations for prior authorizations
- Assisted Nurse Practitioners and Physicians in several states to appropriately apply care levels using established precertification process
- Gathered information and applied appropriate clinical criteria determining medical necessity for requested service using appropriate clinical criteria for all lines of business
- Maintain high standards in all aspects of Med Management / Prior authorization
- Attained Team Lead status within 12 months of employment.
Education
Bachelor of Science - Health Care Admin/ Nursing
Univeristy of Phoenix
Phoenix, AZDiploma - Nursing
Citrus Community. College
1992
Medical Assistant
Northwest College
West Covina, CA04.1989
Skills
- Utilization Management
- Determine Medical Necessity
- Critical Thinking
- Medicare Subject Matter Expert
- Compliance Issues
- Business Unit Oversight
- Patient Health Information Access
Accomplishments
- Arizona State Licensed Practical Nursing License with multi-state privileges since 1994
- Active unencumbered Ohio, Michigan ,New Jersey and California State Practical / Vocational Nursing Licenses.
Timeline
Utilization Review Nurse Manager
Oscar Health
07.2018 - Current
Director Case
La Estancia Nursing & Rehabilitation
11.2016 - 07.2018
Utilization Review Nurse
Conifer Health/ Phoenix Health Plan
10.2015 - 11.2016
Prior Authorization Supervisor
Health Choice
04.2015 - 10.2015
Nurse Auditor, Utilization Review
Mercy Care Plan
09.2008 - 04.2015
Nurse, Team Lead
United Health Group
06.2006 - 09.2008
Bachelor of Science - Health Care Admin/ Nursing
Univeristy of Phoenix
Diploma - Nursing
Citrus Community. College
Medical Assistant
Northwest College
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