MADINAH TAYLOR
Blue Cross Blue Shield of Michigan
Greensboro,NC
1
Certification
14
years of professional experience
RN Care Manager applying InterQual, MCG, and documentation review to support 40+ utilization reviews per week and complete 25+ medical necessity determinations per month in preauthorization and concurrent review decisions. Evaluates 20+ records per day for inpatient, outpatient, and behavioral health cases for medical necessity, level-of-care appropriateness, and discharge readiness. Delivers timely determinations that align with regulatory standards and reduce avoidable delays in care.
Work History
RN Care Manager
5 Months- Develop individualized care plans that align with member needs, coverage guidelines, and discharge goals.
- Assess clinical documentation for completeness and consistency before making utilization recommendations.
- Collaborate with physicians, facilities, and internal teams to support timely care coordination.
- Monitor high-risk members and identify care gaps that may affect treatment adherence or discharge readiness.
- Support discharge planning by confirming follow-up needs and connecting members to appropriate next steps.
- Screen members for behavioral health concerns and route findings to the appropriate care pathway.
- Track utilization trends to identify recurring service patterns and opportunities for improved care management.
- Document clinical assessments, reviewer notes, and authorization outcomes in the member record.
- Maintain organized case notes to support continuity of care across team handoffs and follow-up reviews.
- Communicate coverage decisions clearly to members, providers, and internal partners using professional, timely follow-up.
- Evaluate appeals and grievances by reviewing case details and confirming supporting documentation.
RN Case Manager II
3 Years 1 Month- Managed a caseload of approximately 75 commercial members while delivering utilization-focused case management and care coordination.
- Conducted utilization review and medical necessity assessments using InterQual criteria to support authorization and level-of-care decisions.
- Performed prior authorization and concurrent review activities in line with NCQA standards and organizational policy.
- Developed individualized care plans with providers, LCSWs, and dietitians to improve utilization and member outcomes.
- Used PHQ-9 screening to identify psychosocial barriers affecting care and coordination needs.
- Maintained productivity, quality, and documentation benchmarks in a payer-based environment.
- Coordinated discharge planning and transitions of care to support timely, appropriate next steps for members.
Registered Nurse Supervisor – Population Health Clinical Services
1 Year 3 Months- Supervise a multidisciplinary team supporting utilization review, care coordination, and population health initiatives.
- Oversee prior authorizations, concurrent review, and medical necessity determinations to support appropriate level-of-care decisions.
- Assess care plans for high-risk populations and identify opportunities to improve utilization efficiency and access to appropriate services.
- Monitor quality, productivity, and workflow metrics to support continuous performance improvement and utilization trend analysis.
- Coordinate discharge planning, behavioral health screening, and interdisciplinary case discussions to close care gaps.
Transitions RN Case Manager
1 Year 1 Month- Met [number]% productivity benchmarks while managing telephonic outreach and post-discharge assessments for hospitalized patients.
- Reduced 100+ readmissions per month through transitions-of-care follow-up and timely post-discharge coordination.
- Conducted telephonic outreach to assess discharge readiness, follow-up needs, and service appropriateness after hospitalization.
- Applied utilization review principles to evaluate post-acute services and support appropriate level-of-care decisions.
- Collaborated with physicians, social workers, and community partners to coordinate resources across the care continuum.
- Tracked STAR and quality scores to support ongoing performance monitoring and identify opportunities for improvement.
- Used Epic documentation to capture follow-up actions, care coordination updates, and post-discharge service needs.
RN Case Manager
6 Months- Managed approximately 300 Medicare members in utilization-based case management and concurrent review.
- Conducted inpatient concurrent review for medical and behavioral health cases to assess medical necessity and length-of-stay appropriateness.
- Coordinated interdisciplinary care plans aligned with Medicare guidelines, utilization standards, and transitions of care needs.
- Applied utilization review practices to support consistent medical necessity reviews across inpatient and behavioral health cases.
- Supported care coordination by aligning case actions with Medicare requirements and interdisciplinary treatment plans.
Utilization Review Nurse (Contract)
5 Months- Completed 25+ concurrent reviews per week to assess level of care, treatment necessity, and discharge readiness.
- Reviewed 25+ patient cases per day while applying InterQual and MCG criteria to preauthorization decisions.
- Determined appropriate level of care and treatment necessity by reviewing medical records against InterQual and MCG criteria.
- Documented review findings accurately and maintained adherence to regulatory and accreditation standards.
- Supported discharge readiness by aligning review notes with transitions of care and multidisciplinary collaboration.
RN Care Manager
2 Years- Reviewed 50+% of post-discharge care plans to coordinate DME, specialty referrals, and transitions of care.
- Managed 100+ Medicare members through telephonic assessments and utilization review support.
- Performed telephonic assessments, documented member needs in Epic, and updated care plans for high-risk members.
- Applied InterQual and MCG guidelines to support medical necessity reviews, level-of-care determinations, and prior authorizations.
- Partnered with multidisciplinary teams on HEDIS-aligned quality improvement, behavioral health screening, and clinical documentation improvement.
RN Clinical Care Advocate
10 Months- Processed 20+ prior authorization cases per week for tier exceptions, step therapy, and non-formulary medications.
- Reviewed 25+ utilization requests per day while applying medical necessity criteria for coverage decisions.
- Applied medical necessity criteria to support appropriate coverage determinations across Medicare, Medicaid, and commercial plans.
- Used InterQual and MCG guidelines to strengthen level-of-care reviews and documentation consistency.
- Assisted with staff training on utilization review workflows and best practices.
RN Field Case Manager
1 Year 3 Months- Coordinated 25+ home health, adult day care, and primary care services to support safe transitions and continuity of care.
- Managed 25 Medicaid cases per week to assess service appropriateness and align community resources.
- Conducted utilization reviews to assess medical necessity and resource use for Medicaid members.
- Coordinated home health, adult day care, and primary care referrals to keep care plans aligned across providers.
- Aligned service recommendations with community-based needs to improve access and continuity for Medicaid populations.
RN Staff / Charge Nurse – Emergency Department
1 Year 7 Months- Coordinate 5+% of discharge plans with physicians and care teams to support safe transitions from the ED.
- Triage 5 patients per shift in the emergency department while prioritizing acuity and rapid care escalation.
- Monitor patient status, administer ED interventions, and document changes promptly in the electronic medical record.
- Collaborate with providers and support staff to stabilize high-acuity patients and coordinate timely care during busy shifts.
- Support behavioral health screening and develop care plans that address immediate safety needs and next-step follow-up.
Education
Bachelor of Science - Nursing
Skills
Utilization review & utilization management
Medical necessity & level-of-care determinations
Prior authorizations & concurrent review
InterQual & MCG guidelines
Clinical documentation improvement
Discharge planning & transitions of care
Population health & high-risk member management
Multidisciplinary collaboration
Behavioral health screening
Care plan development
Clinical documentation auditing
Denial management
Peer-to-peer review coordination
Appeals and grievances
Epic EMR
CMS coverage guidelines
Interdisciplinary care conference facilitation
Care gap closure
Utilization trend analysis
Certification
Active NC RN License (Multistate)
Personal Information
Title: Registered Nurse – Utilization Review / Utilization Management
Timeline
RN Care Manager
Blue Cross Blue Shield of Michigan
05.2026 - CurrentRead More
RN Case Manager II
Capital Blue Cross
01.2022 - 02.2025Read More
Registered Nurse Supervisor – Population Health Clinical Services
UNC Health Alliance
09.2020 - 12.2021Read More
Transitions RN Case Manager
UNC Health Alliance
08.2019 - 09.2020Read More
RN Case Manager
UNC Health Alliance
02.2019 - 08.2019Read More
Utilization Review Nurse (Contract)
Aerotek Staffing Agency (Cone Health)
03.2018 - 08.2018Read More
RN Care Manager
Humana Inc.
03.2016 - 03.2018Read More
RN Clinical Care Advocate
UnitedHealth Group
05.2015 - 03.2016Read More
RN Field Case Manager
Mecklenburg County Health Department
02.2014 - 05.2015Read More
RN Staff / Charge Nurse – Emergency Department
Moses Cone Health System
07.2012 - 02.2014Read More
North Carolina Agricultural and Technical State University
Bachelor of Science from Nursing
Read More