Mayselin Bell-Forbes
Fort Lauderdale,FL
Summary
Self-motivated professional promoting attention to detail and the drive to resolve issues effectively. Calm and poised in the most stressful environments. Seeking the opportunity to join new organization in the role of Utilization Review Nurse.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
Centene
Plantation, FL
03.2022 - Current
- 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.
- 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.
- 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.
- 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.
- Referred cases to secondary review for failure to meet criteria.
Telecommute Utilization Management Nurse
United Healthcare
03.2016 - 03.2022
- Assessed patient eligibility for services and benefits according to insurance policies and guidelines.
- Conducted utilization reviews, concurrent reviews, authorization requests and discharge planning.
- Identified opportunities for improved quality of care through review of clinical documentation.
- Developed case management plans that incorporated medical necessity criteria from payers and other resources.
- Collaborated with healthcare providers to ensure appropriate level of care was provided in a cost-effective manner.
- Monitored treatment progress by reviewing medical records, lab results, physician notes.
- Documented all activities related to utilization management in the electronic medical record system.
- Participated in interdisciplinary team meetings to facilitate development of individualized care plans.
- Adhered to evidence-based standards when making decisions regarding resource utilization.
- Ensured compliance with organizational policies and procedures related to utilization management processes.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Contacted insurance carriers to obtain authorizations for services delivered to patients.
- Referred cases to secondary review for failure to meet criteria.
Education
Master of Science - Nursing Education
University of Phoenix
Arizona City, AZ09-2009
Skills
- Utilization review
- Discharge planning coordination
- Clinical assessment
- Plan of care support
- Communication
- Interpersonal and written communication
- Patient transfers and transitions
- Physician consultations
Certification
- RN
- CCM
- CRM
- BC-RN
- PRI Certification New York
Affiliations
Hobbies are reading, gardening, and cooking.
Accomplishments
- Listed in the Cambridge WHO'S WHO Honours Edition 2006–2007
- Special Commendation from the Director of Metro Rail Services, Miami, Florida, for providing assistance to a passenger who suffered a seizure
References
References available upon request.
Timeline
Utilization Review Nurse
Centene
03.2022 - Current
Telecommute Utilization Management Nurse
United Healthcare
03.2016 - 03.2022
Master of Science - Nursing Education
University of Phoenix
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