Martine Wheeler
Homewood,IL
Summary
Skilled Utilization Review Nurse offering talents in continuous assessments and clinical records oversight. Pleasant individual with 20 years in the nursing field. Ready to join new company that appreciates attention to detail and exemplary clinical review skills.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
Humana Insurance Company
Oak Brook, IL
07.2021 - Current
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Provided education to providers regarding utilization management processes and protocols.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Facilitated communication between payers, providers and patients concerning authorization issues or concerns.
- Referred cases to secondary review for failure to meet MCG criteria.
Registered Nurse
Eating Recovery Center
Chicago, Illinois
09.2024 - Current
- Monitored and managed various treatment and care interventions for patients with eating disorders and mental illness.
- Administered medications, tracked dosages, and documented patient conditions.
- Provided emotional support to patients and their families during difficult times.
Rehab Registered Nurse Clinical Liaison
Presence Resurrection Medical Center
Chicago, IL
05.2020 - 08.2024
- Performed initial assessment of patient's medical needs and developed a plan for care.
- Provided education to patients, families, and staff regarding the disease process, treatments, medications, and self-care.
- Conducted daily rounds in assigned units to assess patient care needs.
- Coordinated with physicians and other healthcare professionals to ensure quality patient outcomes.
- Monitored patient progress and reported changes in condition to appropriate personnel.
- Educated multidisciplinary teams on evidence-based practice guidelines related to specialty areas of nursing practice.
Utilization Review Registered Nurse (Pre Auth)
Humana Insurance Company
Oak Brook, IL
09.2015 - 07.2021
- Conducted in-depth assessments of patient medical records to identify cost-effective treatment options for skilled nursing facilities.
- Monitored quality performance indicators for utilization review activities related to clinical outcomes, safety, timeliness, efficiency, effectiveness and patient satisfaction scores.
- Maintained detailed documentation of all utilization review activities according to applicable standards.
- Educated providers on current clinical guidelines, best practices and regulatory requirements.
- Developed strategies to reduce unnecessary hospital admissions and readmissions through proactive case management interventions.
- Responded promptly to inquiries regarding authorization requests from providers or patients.
- Performed concurrent reviews of medical records during active episodes of care.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Reviewed patient admissions to determine medical necessity as directed by CMS criteria.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Referred cases to secondary review for failure to meet CMS criteria.
Case Manager
Humana Insurance Company
Oak Brook, IL
09.2014 - 09.2015
- Managed a case for of 100+ Humana members that were in the Medicare/Medicaid population
- Assessed clients' needs, developed service plans and monitored progress towards goals.
- Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.
- Provided crisis intervention support for clients in emergency situations.
- Developed individualized care plans with input from clients and their families.
- Collaborated with medical professionals to coordinate treatment plans for clients.
- Maintained accurate case records and documentation according to agency guidelines.
- Monitored client progress through regular follow-up contacts.
Registered Nurse Case Manager
Presence Resurrection Medical Center
Chicago, IL
02.2016 - 06.2020
- Provided direct patient care and management of acute medical issues in a timely manner.
- Assessed, planned, implemented and evaluated individualized nursing care plans for each patient.
- Developed patient care plans, overall patient health assessments and evaluations.
- Actively participated in family and patient planning processes.
- Assessed and reviewed patients for discharge and planning and integrated services for patients requiring home care, home infusion and durable medical equipment (DME).
Registered Nurse, Behavioral Health
Advocate Christ Medical Center
Oak Lawn, IL
05.2000 - 09.2012
- Served as Charge Nurse as needed on an inpt behavioral psychiatric unit
- Provided direct patient care, including assessment and evaluation of physical, mental and behavioral health.
- Performed crisis intervention when needed to deescalate volatile situations.
- Maintained accurate documentation of patient progress notes and clinical assessments utilizing Electronic Health Records.
- Educated patients and families about diagnosis, treatments options and potential side effects associated with medications prescribed by physicians.
- Worked closely with psychiatrists and other medical staff members to coordinate comprehensive patient care.
- Provided supportive counseling services through individual psychotherapy sessions.
- Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
- Administered local, inhalation or intravenous anesthetics to patients undergoing procedures.
- Conducted specified laboratory tests to help detect conditions and determine diagnosis.
- Facilitated psychoeducational classes on topics such as stress management, communication, anger management.
- Adhered to ethical principles of autonomy, beneficence, nonmaleficence and justice while providing nursing care.
Nurse Care Coordinator
Threshold Services
Chicago, IL
06.2012 - 01.2014
- Monitored patient progress and adjusted care plans accordingly.
- Conducted home visits to assess patient condition and provide necessary services.
- Developed discharge plans that included post-discharge follow-up instructions and referrals as needed.
- Managed a caseload of 50 individuals with mental and physical health needs
- Assisted individuals in IMD's and nursing homes to move into supportive community housing under the Williams Consent Decree
- Scheduled appointments for patients requiring specialty or ancillary services.
Home Health Nurse
Ingalls Hospital
Harvey, IL
02.2014 - 09.2014
- Assessed patient health by conducting physical examinations and evaluating medical histories.
- Provided home health care services such as wound care, medication administration, and IV therapy.
- Developed personalized care plans for patients based on individual needs.
- Educated patients and families about disease management, lifestyle changes, nutrition, and preventive healthcare measures.
- Monitored vital signs such as blood pressure or pulse rate to detect any changes in a patient's condition.
- Initiated referrals to appropriate community resources when needed.
Education
Bachelor of Science - Nursing
Governors State University
Park Forest, IL05-2011
Associate of Science - Nursing
Richard J Daley
Chicago, IL05-2004
Skills
- Records analysis
- Milliman Guidelines
- Documentation
- Resourceful
- Proficient in Microsoft Office
- Team player
- Interpersonal and written communication
Certification
- Active licensed in IL, IA, WI, KS, MN, ND, SD
Timeline
Registered Nurse
Eating Recovery Center
09.2024 - Current
Utilization Review Nurse
Humana Insurance Company
07.2021 - Current
Rehab Registered Nurse Clinical Liaison
Presence Resurrection Medical Center
05.2020 - 08.2024
Registered Nurse Case Manager
Presence Resurrection Medical Center
02.2016 - 06.2020
Utilization Review Registered Nurse (Pre Auth)
Humana Insurance Company
09.2015 - 07.2021
Case Manager
Humana Insurance Company
09.2014 - 09.2015
Home Health Nurse
Ingalls Hospital
02.2014 - 09.2014
Nurse Care Coordinator
Threshold Services
06.2012 - 01.2014
Registered Nurse, Behavioral Health
Advocate Christ Medical Center
05.2000 - 09.2012
Bachelor of Science - Nursing
Governors State University
Associate of Science - Nursing
Richard J Daley