Necia Workman
Richmond Heights,Mo.
Summary
Dynamic healthcare professional with extensive experience in utilization and case management. Excelling in medical necessity reviews and case management. Proven ability to lead teams and implement process improvements, ensuring compliance with healthcare regulations. Skilled in developing patient care plans and conducting needs assessments, driving quality outcomes in complex care environments.
Overview
35
35
years of professional experience
Work History
Utilization Review Nurse
Contigo Healthcare
Charlotte, NC
03.2021 - 12.2025
- Performed reviews for inpatient, skilled nursing, and behavioral health admissions, including outpatient procedures and home health care authorizations.
- Conducted medical necessity reviews for self-funded groups based on specific benefit structures.
- Applied Milliman Guidelines, NCCN, and Up-to-Date resources for informed clinical decision support.
- Escalated complex cases to Medical Directors for expert review and resolution.
- Trained new staff to ensure adherence to protocols and standards.
- Collaborated in interdisciplinary team meetings to enhance patient care strategies.
Inpatient Care Manager
United Healthcare
Minneapolis, MI
01.2016 - 09.2020
- Coordinated discharge planning, identifying internal and community-based support resources to facilitate smooth transitions for patients.
- Conducted medical necessity reviews for inpatient and subacute admissions for Medicaid and Medicare members using clinical judgment and established criteria.
- Referred complex cases to Medical Directors for comprehensive evaluation, ensuring appropriate care decisions.
Oncology Case Manager
American Healthholdings
New Albany, OH
09.2014 - 10.2015
- Coordinated treatment plans for adult and pediatric oncology patients to ensure comprehensive care.
- Reviewed medical necessity for inpatient and outpatient chemotherapy, utilizing MCG, NCCN Guidelines, and Lexicomp.
Nurse Case Manager Senior
Anthem BlueCross BlueShield
St. Louis, MO
11.2010 - 12.2013
- Managed complex case plans for adult and pediatric members, ensuring comprehensive care aligned with individual needs.
- Coordinated resources across healthcare teams to address identified needs and enhance support for treatment plans.
- Collaborated with Medical Directors and Physician Advisors to refine treatment plans.
- Conducted assessments to identify individual needs and establish targeted goals.
- Verified accuracy and completeness of physician orders to facilitate seamless implementation of service plans.
Manager II Medical Management
Anthem BlueCross BlueShield
St. Louis, MO
01.2001 - 12.2010
- Supervised medical management department operations, including precertification for inpatient, outpatient, and ancillary services.
- Managed development of 28 to 60 associates across multiple offices in MO, WI, and remote locations.
- Conducted hiring, performance reviews, and performance improvement plans for staff.
- Implemented process improvements and workflow policies, enhancing regulatory compliance.
- Monitored metrics to identify and resolve issues affecting members, providers, and health plan utilization management.
- Participated in NCQA, URAC, and DOI audits to maintain quality standards.
- Oversaw UM appeals from 2006 to 2008 while managing daily operations of the appeals department.
- Developed system-generated letters to optimize workflow within the department.
- Implemented quality assurance measures to uphold service excellence and regulatory compliance.
- Facilitated team meetings to align objectives and promote collaboration.
Telephonic Review Nurse
Anthem BlueCross BlueShield
St. Louis, MO
06.1994 - 06.1996
- Conducted telephonic reviews for pre-admission and continued stay certifications, collaborating with physician office staff, hospital UR staff, and members to verify compliance and quality care.
Registered Nurse, Pediatric Intensive Care Unit
St. Louis Children’s Hospital
St. Louis, MO
10.1990 - 10.1994
- Provided comprehensive care for patients aged newborn to 22 years in a 22-bed unit.
- Managed multidisciplinary patient cases across medicine, surgery, trauma, orthopedics, and transplants, ensuring comprehensive care coordination.
- Collaborated with healthcare teams to optimize patient outcomes, integrating services for holistic care.
Education
Diploma -
Barnes Hospital School of Nursing
St. Louis, MOClasses toward BSN
University of Missouri St. Louis
Skills
- Medical necessity reviews
- Clinical decision support
- Case management and discharge planning
- Staff training and team leadership
- Problem solving
- Healthcare regulations and compliance
- Medicaid and Medicare knowledge
- Needs assessment and patient care plans
- Prior authorization processes
- InterQual, Milliman, and NCCN criteria
- Appeals management
References
References available on request
Registration - License
Missouri State Board of Nursing - Multistate License
Timeline
Utilization Review Nurse
Contigo Healthcare
03.2021 - 12.2025
Inpatient Care Manager
United Healthcare
01.2016 - 09.2020
Oncology Case Manager
American Healthholdings
09.2014 - 10.2015
Nurse Case Manager Senior
Anthem BlueCross BlueShield
11.2010 - 12.2013
Manager II Medical Management
Anthem BlueCross BlueShield
01.2001 - 12.2010
Telephonic Review Nurse
Anthem BlueCross BlueShield
06.1994 - 06.1996
Registered Nurse, Pediatric Intensive Care Unit
St. Louis Children’s Hospital
10.1990 - 10.1994
Diploma -
Barnes Hospital School of Nursing
Classes toward BSN
University of Missouri St. Louis