Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Michele F. Block

Lincoln,NE

Summary

Seasoned nursing professional offering proven clinical knowledge, natural interpersonal strengths and technical abilities. Knowledgeable about utilization management processes of prior authorization, admission, concurrent review, and interdisciplinary collaboration focused on optimizing member care and support. Quality-focused and efficiency-driven leader.

Overview

30
30
years of professional experience
1
1
Certification

Work History

UM Nurse RN

Optum
03.2024 - Current
  • Evaluated medical necessity and appropriateness of care to ensure compliance with regulations.
  • Ensured compliance with regulatory requirements through consistent adherence to established policies and procedures for utilization management nursing practice.
  • Supported evidence-based decision making through research and application of current industry guidelines for utilization management.

Triage/Nurse SME

FPO, Outreach LLC.
10.2022 - Current
  • Triage physician reviews types: utilization, case management, medical review and appeals to most appropriate MD specialty
  • Answer questions for appropriate handling of reviews
  • Train MD's on EMR system and documentation of reviews
  • Liaison with Third Party Administrator
  • Schedule Peer to Peer's for MD's
  • Managed time efficiently in order to complete all tasks within deadlines
  • Demonstrated respect, friendliness and willingness to help wherever needed
  • Organized and detail-oriented with a strong work ethic
  • Used critical thinking to break down problems, evaluate solutions and make decisions
  • Developed and maintained courteous and effective working relationships
  • Identified issues, analyzed information and provided solutions to problems

Associate Manager

AHH, Inc, American Health Holding, Inc, PHG AHH
12.2018 - 08.2022
  • Supervises precertification and concurrent function, acts as subject matter expert and provides guidance on Precertification and Concurrent Review processes and functions
  • MCG criteria utilization
  • Set and enforced performance and service standards to keep consistent, high-quality environment devoted to customer satisfaction.
  • Remedied issues and conflicts among workers using negotiation and active listening.
  • Oversaw training and onboarding process for all newly hired employees within UM team 2.
  • Mentored and supported 18-22 Utilization department employees to create strong workplace culture.
  • Supervised day-to-day operations to meet performance, quality and service expectations.
  • Helped with planning schedules and delegating assignments to meet coverage and service demands.
  • Mentored team members to enhance professional development and accountability in workplace.
  • Increased employee performance and job satisfaction to strengthen retention and engagement.

Team Lead, nurse consultant

Aetna, Incorporated
12.2015 - 12.2018
  • Training new staff in 2 software systems
  • QA denial letters prior to sending
  • Met caseload requirements for TAT
  • Conducts initial and continued stay reviews
  • Daily reviews census to ensure entire team is meeting TAT
  • Assist other team members with questions/issues so that productivity & outcome goals are met
  • Maintain Confidentiality
  • InterQual/MCG criteria utilization
  • Six Sigma Lean, yellow certification
  • Trained new team members by relaying information on company procedures and safety requirements.
  • Coached team members in techniques necessary to complete job tasks.
  • Evaluated employee skills and knowledge regularly, training, and mentoring individuals with lagging skills.
  • Reviewed medical records and summarized care.
  • Conducted training and mentored team members to promote productivity, accuracy, and commitment to friendly service.
  • Promoted high standards through personal example to help each member understand expected behaviors and standards.
  • Mentored and guided employees to foster proper completion of assigned duties.

Utilization Management Nurse Consultant

Coventry HealthCare of Nebraska
03.2011 - 11.2015
  • Met TAT for compliance
  • Acute care, SNF and LTACH reviews-initial and continued stay via fax, telephone, EMR access
  • Case load: 20-30 cases
  • Escalate cases for MD review
  • Proactive discharge planning
  • 100% on quality audit reviews
  • InterQual criteria utilization
  • Performed prior authorization review of services requiring notification
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services
  • Performed admission reviews based for medical necessity based upon InterQual/MCG specification
  • Evaluated patient histories, complaints, and current symptoms
  • Performed prior authorization review of services requiring notification.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Submitted cases for criteria failures and helped facilitate resolutions and approvals.

LTACH Registered Nurse

Madonna Rehabilitation Hospital
06.2010 - 03.2011
  • Provide direct patient care for team of 3-4 patients
  • Collect and document data of patient's condition
  • Educate patients for medications, fluid restrictions, self -care promotion
  • Promote infection control practices
  • IV medication administration
  • Ventilator cares
  • Burn cares
  • Peritoneal dialysis
  • Discharge planning

LTACH Licensed Practical Nurse

Madonna Rehabilitation Hospital
08.2004 - 06.2010
  • Provide direct patient care for team of 3-4 patients
  • Collect and document data of patient's condition
  • Educate patients for medications, fluid restrictions, self -care promotion
  • Promote infection control practices

Licensed Practical Nurse- Night Charge Nurse

Maranatha Village
08.2003 - 08.2004
  • Supervised a team of 4 nurse aides for the care of 25 residents
  • Provided medications & treatments for these individuals
  • Fostered an environment of learning and teamwork for staff

Licensed Practical Nurse- Day Charge/Treatment Nurse

Alpine Village
09.1995 - 08.2003
  • Supervised up to 8 nurse aides for the care of a 75 bed long-term nursing facility
  • Handled communication with physicians, documenting and carrying out physician orders
  • Provided support and education for residents and family members
  • Assisted in staff scheduling

Education

Bachelor's of Science - Nursing

Clarkson College
05.2010

Practical Nursing Diploma -

Northeast Community College
Norfolk, NE
08.1995

Skills

  • Analytical reasoning
  • Detail-oriented organization
  • Empathetic support
  • Providing clear answers
  • Precise documentation
  • Positive mindset
  • Responsive to new challenges
  • Collaborative team member
  • Healthcare team management
  • Oversight of case processes
  • Effective communication abilities

Certification

  • Registered Nurse NE License - 06/10-10/26
  • Registered Nurse MN License - 02/23-02/27
  • BLS Training 10/24-10/26

Timeline

UM Nurse RN

Optum
03.2024 - Current

Triage/Nurse SME

FPO, Outreach LLC.
10.2022 - Current

Associate Manager

AHH, Inc, American Health Holding, Inc, PHG AHH
12.2018 - 08.2022

Team Lead, nurse consultant

Aetna, Incorporated
12.2015 - 12.2018

Utilization Management Nurse Consultant

Coventry HealthCare of Nebraska
03.2011 - 11.2015

LTACH Registered Nurse

Madonna Rehabilitation Hospital
06.2010 - 03.2011

LTACH Licensed Practical Nurse

Madonna Rehabilitation Hospital
08.2004 - 06.2010

Licensed Practical Nurse- Night Charge Nurse

Maranatha Village
08.2003 - 08.2004

Licensed Practical Nurse- Day Charge/Treatment Nurse

Alpine Village
09.1995 - 08.2003

Practical Nursing Diploma -

Northeast Community College

Bachelor's of Science - Nursing

Clarkson College

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