Mia Smith

Telephonic Specialty Medication Utilization Review for OPTUM pharmacy-Aug 2020-Oct 2021

• Performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of inpatient & outpatient services/Specialty Medication requests following evaluation of medical guidelines and benefit determination. Solves moderately complex problems and/or conducts moderately complex analyses with minimal guidance. Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, and online resources.) Prioritize cases based on appropriate criteria, ensuring compliance with applicable federal/state and company requirements and mandates all lines of business.

Provided effective telephone triage to assess patient needs. Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, management and lifestyle options, as well as teaching self-injections. Performed & interpreted benefit investigations and prior authorizations for specialty medications & procedures. Refilled prescriptions for patients under rheumatology protocol. Direct patient care with intake, therapeutic injections, collection of lab specimens, assisting with joint aspirations. Trained new nurses in proper techniques, care standards, operational procedures and safety protocols.

Led successful team comprised of RNs, LPNs and ancillary staff. Provide skilled nursing care to medically complex patients who require 24/7 nursing care services. Interaction with multi-disciplinary team of doctors, nurses, and technicians to provide excellent care and comfort to patients. Afforded firm, fair, and consistent leadership, training, and evaluation for nursing staff personnel, focusing on primary and effective patient care and assessment practices. Maintaining staff coverage, scheduling, and enforcement of disciplinary actions when appropriate. Engage in active resident conflict resolution and risk assessment that require nursing intervention and ongoing care assessment. Keep accurate patient charts and document all pertinent information and medication requirements. Function as patient advocate and implement nursing process covering twenty skilled patients directly while responsible for one hundred-eight patients total (skilled and ICF) per shift.