MARGARITA JACKSON
Melbourne,FL
Summary
Skilled Utilization Review Nurse is offering talents in continuous assessments and clinical records oversight—a pleasant individual with over 35 years in the nursing field. I am ready to join a new company that appreciates attention to detail and exemplary clinical review skills.
Overview
3
3
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
Cigna
Bloomfield , CT
10.2022 - 03.2024
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Analyzed data from patient surveys, interviews and other sources to assess healthcare service quality.
- Provided education to providers regarding utilization management processes and protocols.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Generated reports related to utilization management activities such as length of stay trends, denials rates.
- Performed discharge planning including referrals for post-acute care services when appropriate.
- Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions.
- Facilitated communication between payers, providers and patients concerning authorization issues or concerns.
- Attended conferences and training sessions related to utilization review topics such as best practices or new technologies.
- Reviewed patient admissions to determine medical necessity as directed by Miliman criteria.
Nursing Supervisor
Maximus Federal Services
McLean , VA
03.2022 - 07.2022
- Developed and implemented nursing policies and procedures to ensure quality patient care.
- Provided staff education and training on new equipment, techniques, and processes.
- Conducted performance reviews of nursing staff members to identify areas for improvement.
- Resolved conflicts among medical staff in a professional manner.
- Coordinated scheduling of staff to meet departmental needs.
- Maintained accurate records related to staffing, budgeting, patient care, and other administrative duties.
- Facilitated communication between physicians, nurses, and other healthcare providers regarding patient care issues.
- Evaluated clinical practices and implemented changes as needed based on feedback from staff members or research data.
- Reviewed incident reports involving nursing staff members or patients to determine appropriate corrective action.
- Trained other nurses on patient care and daily tasks, supporting growth and professional development.
- Managed team of 12 registered nurses.
RN Case Manager
Adventist Health System
Clearlake , CA
08.2021 - 02.2022
- Communicated regularly with family members regarding patient care needs and progress toward goals.
- Provided emotional support and counseling to patients dealing with chronic illness or end-of-life issues.
- Assessed patient's physical, mental, and psychosocial health status to develop individualized care plans.
- Provided direct nursing care such as wound dressing changes, IV therapy, medication administration and patient education.
- Monitored and evaluated effectiveness of treatment plans and interventions.
- Collaborated with physicians, nurses and other healthcare professionals to ensure optimal patient outcomes.
- Developed discharge plans for patients transitioning from acute care settings to home or alternate facilities.
- Coordinated medical services between primary care providers, specialists, hospitals and outpatient clinics.
- Facilitated referrals to community resources for additional support services.
- Maintained accurate documentation of patient progress in the electronic health record.
- Conducted weekly interdisciplinary team meetings to review case management activities for assigned caseloads.
- Educated patients on disease prevention strategies, wellness promotion techniques and lifestyle modifications.
- Identified high-risk cases requiring intensive monitoring or specialized interventions.
- Actively participated in multidisciplinary rounds discussing complex cases with members of the healthcare team.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
Utilization Review Specialist
Aetna
Hartford , CT
03.2024 - present
- Analyzed treatment plans for appropriateness, effectiveness and medical necessity in accordance with established criteria.
- Conducted concurrent reviews to monitor the ongoing appropriateness of services provided to members.
- Collaborated with physicians, nurses, case managers, discharge planners, social workers and other healthcare professionals to develop a comprehensive plan of care within specified guidelines.
- Interpreted coverage policies and benefit provisions as they relate to the clinical setting.
- Provided consultation on appropriate use of services to staff members including utilization management strategies.
- Monitored trends in utilization patterns and made recommendations for improvement as needed.
Education
Master of Science - Nursing Education
Walden University
Minneapolis, MN04-2012
Skills
- Communication
- Medical Coding
- Records analysis
- Interpersonal and written communication
- HIPAA Compliance
- Home Health Care
- Patient transfers and transitions
- Discharge Planning
- Utilization Management
- Quality Improvement
- Insurance Verification
- Medicaid knowledge
- Documentation And Reporting
- Performing assessments
Affiliations
Former member of the Satellite beach Lions Club
Accomplishments
- Who's Who in America 2022
Certification
- Certified Case Manager
- American Heart CPR
References
References available upon request.
Timeline
Utilization Review Specialist
Aetna
03.2024 - present
Utilization Review Nurse
Cigna
10.2022 - 03.2024
Nursing Supervisor
Maximus Federal Services
03.2022 - 07.2022
RN Case Manager
Adventist Health System
08.2021 - 02.2022
Master of Science - Nursing Education
Walden University
- Certified Case Manager
- American Heart CPR
Similar Profiles
Corinne JohnsonCorinne Johnson
Customer Service Analyst at CignaCustomer Service Analyst at Cigna
Yesenia Perez PaezYesenia Perez Paez
Claims Representative at CignaClaims Representative at Cigna
Alexandrea AlburyAlexandrea Albury
Workforce Management Analyst at CignaWorkforce Management Analyst at Cigna