Melanie Butara
Painesville,OH
Summary
Accomplished Utilization Review Nurse from Cleveland Clinic, adept in HIPAA compliance and enhancing care plans. Excelled in applying InterQual criteria and fostering physician relations, ensuring quality improvement. Proven track record in streamlining processes, with exceptional interpersonal communication skills, contributing to efficient healthcare delivery and patient satisfaction.
Overview
3
3
years of professional experience
Work History
Utilization Review Nurse
Cleveland Clinic
Mayfield Heights, Ohio
03.2022 - Current
- Provided education to providers regarding utilization management processes and protocols.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Collaborated with case managers to facilitate timely discharge planning and transition of care.
- Coordinated with healthcare teams to develop care plans that meet patient needs and insurance coverage.
- Reviewed and updated utilization review criteria and guidelines to reflect current standards of practice.
- Identified opportunities for improvement in processes related to utilization management functions.
- Referred cases to secondary review for failure to meet criteria.
- Participated in multidisciplinary team meetings to discuss patient care issues and utilization review findings.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Educated healthcare providers on utilization review processes, criteria, and best practices.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions.
- Provided feedback to healthcare providers on clinical documentation improvement to support utilization review.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Prioritized and organized tasks to efficiently accomplish service goals.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
Education
Bachelor of Science - Nursing
Chamberlain College of Nursing
Chicago, IL06-2020
Skills
- Plan of care support
- HIPAA compliance
- Quality improvement
- InterQual criteria
- Physician consultations
- Prior authorization
- Interpersonal and written communication
Timeline
Utilization Review Nurse
Cleveland Clinic
03.2022 - Current
Bachelor of Science - Nursing
Chamberlain College of Nursing
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