Nicole Young

Humana Utilization Management Concurrent Nurse

Prepared time-sensitive inpatient concurrent reviews for Medical Director determination of medical necessity using MCG Guidelines. conducted detailed clinical reviews of inpatient admission, evaluated severity of illness and intensity of service criteria, and complied concise clinical summaries to support medical director review and coverage determination.

HUMANA PROVIDER DISPUTES FER NURSE

Performed retrospective utilization reviews for Medical Director consideration, conducting comprehensive evaluations of entire inpatient hospital stays to assess medical necessity, level of care appropriateness, and compliance with established clinical criteria, regulatory guidelines, and payer policies. Synthesized complex clinical documentation and presented finding to support medical director determination.

HUMANA PREAUTHORIZATION NURSE REVIEWER (2020-2021)

Conduct reviews of surgical and medical CPT-coded services to determine medical necessity and benefit eligibility in accordance with established coverage criteria. Obtain and review clinical documentation from providers to support authorization determinations. Communicate directly with provider offices to request additional records when needed and issue timely approval or denial decisions based on clinical evidence policy guidelines, and regulatory requirements.

HUMANA PROVIDER DISPUTES NURSE REVIEWER (2014-2020)

Reviewed disputed services including applicable CPT laboratory and procedure codes, for medical necessity and experimental/investigational coverage determination.

Evaluation was completed using applicable National Coverage Determination, Local Coverage Determinations, the Center for Medicare and Medicaid Services Medicare Benefit Policy/ Claims processing Manuals, and Humana Medical Coverage Policies. Determination was based on established coverage criteria, clinical documentation submitted and supporting policy guidelines