Utilization Management Nurse Consultant with expertise in HIPAA compliance, clinical assessment, and care coordination. Proven ability to enhance healthcare services and promote effective benefit utilization.
Work History
Utilization Management Nurse Consultant
7 Years
CVS Health | 08.2019 - Current
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management process
Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgement to render determination/recommendation along the continuum of care
Identifies members for referral opportunities to integrate with other products, services and programs Identifies opportunities to promote effectiveness of healthcare services and benefit utilization
Consults and lends expertise to other internal and external constituents
Utilization Review Nurse
1 Year 1 Month
Lake Health System | 07.2018 - 08.2019
Utilization Review/Gatekeeping
Care Coordination assisting with discharge planning
Reviewed clinical documentations to determine requirements of inpatient or observation status utilizing MCG and Interqual.
Monitored length of stay while collaborating with physicians and case managers
Medical Surgical Registered Nurse
10 Years 6 Months
Lake Health Hospital | 01.2008 - 07.2018
Acted in Charge Nurse role managing unit throughout in collaboration with other units, facilitate teamwork and prioritization of patient care needs, act as resource for nursing and administrative staff
Provided training to new employees to foster professional growth and development and assure the highest level of patient care.
Worked collaboratively with interdisciplinary healthcare team members to plan a safe discharge and to optimize patient care outcomes