Margarita E Jackson
Melbourne,FL
Summary
Energetic individual offering 10 years' experience in reviewing compliance standards and auditing charts. Astute Utilization Review Nurse knowledgeable in medical data gathering, analysis and authorization obtainment.
Overview
2
2
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
Aetna, a CVS Health
Hartford, CT
03.2024 - Current
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Collaborated with staff members in group meetings to identify issues and find cost-effective solutions.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
Nursing Supervisor
Maximus Federal Services
Virginia Beach, VA
03.2022 - 07.2022
- Answered questions and addressed concerns from employees promptly through email, phone and in person.
- Developed and implemented orientation documents for new agents and new supervisors at the call center.
- Reported to the Manager of the call center
- Managed 17 RN direct reports.
- Maintained quality by reviewing open and closed charts
- Lead the team to be number one in the call center for four months.
- Held team meetings via Webex, held side by side mentoring for the nurses using the Triage handbook.
- Managed the call center of seven teams in the absence of the manager.
- Provided clinical advice to the team according to approved algorithms for the triage of the veteran caller or family member.
- Real time management of agents utilization the Genesys system.
Utilization Review Nurse
Cigna-HealthSpring
, CT
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Referred cases to secondary review for failure to meet Millman criteria.
- Managed processes pertaining to denials and potential denials as outlined by insurance carriers.
- Coordinated with other departments within the organization regarding changes in policy or procedure implementation.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
Education
Master of Science - Education
Walden University
Minneapolis, MN04-2012
Skills
- Healthcare regulations
- Outpatient Care
- Medical Coding
- Quality Improvement
- Discharge Planning
- Palliative Care
- Performing assessments
- Documentation And Reporting
- Home Health Care
- Utilization review
- Patient Care Plans
- Needs Assessment
- HIPAA Compliance
- Insurance Verification
Certification
- Certification Case Management
- RN license: Florida muliti-state, California
- Basic Life Support certification
References
References available upon request.
Timeline
Utilization Review Nurse
Aetna, a CVS Health
03.2024 - Current
Nursing Supervisor
Maximus Federal Services
03.2022 - 07.2022
Utilization Review Nurse
Cigna-HealthSpring
Master of Science - Education
Walden University