Mallory Vice
Wallingford,KY
Summary
Efficient Utilization Management Nurse known for productivity and ability to complete tasks swiftly yet thoroughly. Possess specialized skills in patient care coordination, healthcare policy compliance, and medical necessity criteria evaluation. Excel in communication, problem-solving, and teamwork, ensuring seamless operations across healthcare teams.
Overview
1
1
Certification
3
3
years of post-secondary education
14
14
years of professional experience
Work History
Utilization Management Nurse
Humana
Louisville, KY
01.2018 - Current
- Reviewed prior authorization requests for medical necessity using utilization management guidelines and clinical criteria.
- Applied clinical guidelines to prior authorization determinations and utilization reviews.
- Reviewed Humana utilization cases, ensuring compliance with medical necessity and benefit coverage standards.
- Documented and analyzed clinical findings in Humana care management systems to support effective care coordination.
- Collaborated with physicians and care teams to coordinate reviews.
- Communicated coverage decisions, clinical rationale, and next steps to providers and members.
- Use my clinical knowledge, communication skills, and independent critical thinking skills toward interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for Humana members.
Humana At Home Care Manager
Humana
Louisville, KY
02.2016 - 01.2018
- Coordinated management of Medicare participants' healthcare needs, enhancing overall well-being.
- Monitored patient care telephonically, ensuring timely interventions and support.
- Maintained accurate, detailed reports and records to support effective patient care.
- Recommend medical devices, or other forms of treatment, such as physical therapy, inhalation therapy, or related therapeutic procedures.
Home Health Nurse
St. Claire Regional Medical Center
Morehead, Kentucky
01.2015 - 02.2016
- Administered medications and treatments during home visits.
- Provided home health care services such as wound care, medication administration, and IV therapy.
- Monitor, record, and report symptoms or changes in patients' conditions.
- Modified patient treatment plans based on patients' responses and conditions.
- Coordinated with healthcare team to assess, plan, implement, and evaluate comprehensive patient care plans.
- Educated families on wound care, medications, and safety.
- Assessed homebound patients for St. Claire Regional Medical Center home health needs.
- Consult and coordinate with healthcare team members to assess, plan, implement, or evaluate patient care plans.
- Coordinated discharge follow-up with hospital staff and community services.
- Modify patient treatment plans as indicated by patients' responses and conditions.
- Participated in interdisciplinary team meetings to discuss the progress of each patient's treatment plan.
- Educated patients and families about disease management, lifestyle changes, nutrition, and preventive healthcare measures.
- Developed personalized care plans for patients based on individual needs.
- Educated families on effective wound care techniques, medication management, and safety practices to promote optimal patient recovery.
- Assisted with client personal care needs to foster independence and well-being.
- Assisted patients with activities of daily living and functional mobility to increase comfort and quality of life.
- Answered patient calls, identified issues, and determined how best to provide assistance within parameters established by facility and supervisor.
- Monitored symptoms and reported changes to providers.
- Participated in on-call rotations and delivered after-hours care.
- Responded promptly to emergency calls from clients needing urgent attention at home.
- Planned nursing care with St. Claire Regional Medical Center physicians and care teams.
- Addressed patient care needs, collected vitals, dressed wounds, and managed catheters.
- Instructed family members in basic nursing skills including wound care, injections, catheterization, and other treatments as ordered by the physician.
- Coordinated patient discharge planning with physicians, social workers, case managers, therapists, pharmacists and other healthcare professionals involved in the patient's care plan.
- Conducted laboratory tests to analyze patient samples for diagnosis.
- Conduct assessments of individuals' home or work environments, to identify potential health or safety problems.
- Facilitated patient discharge planning by collaborating with physicians, social workers, case managers, and other healthcare professionals to ensure smooth transitions in care.
- Monitored vital signs such as blood pressure or pulse rate to detect any changes in a patient's condition.
- Order, interpret, and evaluate diagnostic tests to identify and assess patients' condition.
- Conducted regular re-evaluations to address changes in needs and conditions, and introduced revisions to care plans.
- Ensured quality assurance standards are met through regular chart audits and review processes.
- Collaborated with local agencies to ensure continuity of care upon discharge from home health services.
- Utilized electronic health records to document patient care accurately and comprehensively.
- Managed the administration of intravenous (IV) therapies and nutrition.
Registered Nurse, Medical-Surgical Unit
St. Claire Regional Medical Center
Morehead
12.2012 - 01.2015
- Patient Assessments: Perform head-to-toe evaluations, monitor vital signs regularly, and track changes in a patient's condition.
- Administered oral medications, intravenous (IV) infusions, antibiotics, and pain management therapies to ensure effective patient treatment.
- Monitored surgical sites, managed complex wound dressings, and assisted patients in walking to promote recovery and mobility.
- Operated medical devices, including IV pumps, catheters, oxygen tanks, and tube feedings, to support patient care needs.
- Patient and Family Education: Teach patients about their diagnoses, home medications, and what to expect after discharge.
- Operated medical devices including IV pumps, catheters, oxygen tanks, and tube feedings.
Education
Associate Degree in Nursing - Nursing
Maysville Community And Technical College
Maysville, KY 08.2009 - 05.2012
Skills
- Utilization management
- Medical necessity criteria
- Authorization review
- Clinical guidelines
Certification
- Nursing License Kentucky and Nevada
Timeline
Utilization Management Nurse
Humana
01.2018 - Current
Humana At Home Care Manager
Humana
02.2016 - 01.2018
Home Health Nurse
St. Claire Regional Medical Center
01.2015 - 02.2016
Registered Nurse, Medical-Surgical Unit
St. Claire Regional Medical Center
12.2012 - 01.2015
Associate Degree in Nursing - Nursing
Maysville Community And Technical College
08.2009 - 05.2012