Marianne Donohue

• apply independent medical judgment to medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when indicated.
• ensure patients receive the care they need while managing costs and making the best use of available resources — without unnecessary or duplicate services.
• maintain current knowledge and understanding of and regularly apply the laws, regulations, and policies that pertain to the organizational business units and uses clinical judgment in the application.

Microsoft Word

Outlook and Excel

Milliman Criteria

Interqual Criteria.

• Collaborated with interdisciplinary teams to develop comprehensive care plans tailored to individual patient needs.

• Boosted employee retention rates through creating supportive work environments that encourage teamwork and professional growth.
• Streamlined clinic operations by maintaining organized records of patient information, appointment scheduling, and insurance verification.
• Mentored new nursing staff members, sharing best practices for effective communication, time management, and clinical skills development within the outpatient setting.

assess events to determine any over-utilization or under-utilization of services

train, enforce, and monitor the new changes among the nurse team.

ensure healthcare guidelines and NCQA , consistently followed

Conducted Medical Group Audits for the Health Plans

Prepared Correction Action Plans as required