Nikki Casanova

• Conducted comprehensive utilization reviews for patient care plans and services.
• Collaborated with healthcare teams to assess medical necessity and appropriateness.
• Analyzed clinical documentation to ensure compliance with regulatory standards.
• Communicated effectively with providers regarding authorization and denial decisions.
• Educated staff on utilization review processes and best practices for compliance.
• Reviewed treatment plans to identify potential areas for improvement in care delivery.
• Utilized electronic health record systems to track and manage patient information efficiently.
• Participated in interdisciplinary meetings to discuss case management strategies and outcomes.
• Assessed patient medical records to determine the appropriateness of requested services and procedures.
• Served as a resource for staff members seeking guidance on utilization review matters.
• Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
• 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.
• Investigated complaints related to denied claims or treatment plans.
• Performed discharge planning including referrals for post-acute care services when appropriate.
• Use of Milliman and Interqual criteria

• Coordinated patient care plans with multidisciplinary teams.
• Assessed client needs through detailed interviews and evaluations.
• Maintained accurate documentation in electronic health records systems.
• Developed discharge plans to ensure smooth transitions for patients.
• Managed caseloads effectively to prioritize urgent client needs.
• Collaborated with community services to enhance patient support options.
• Provided case management services including intake, assessment, crisis intervention, advocacy, referral and monitoring of families.
• Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.

Use of Milliman criteria. and Interqual for evidence based care guidelines.

Participate in interdisciplinary team meeting. weekly.

• staff Case Manger In ICU and trauma and transplant.
• concurrent reviews of daily admission and continue stay
• Use of internal and Milliman criteria
• review Observation and 1-2 day medicare day patients
• working with Insurance company for continue stay and identifying discharge needs
• Documentation of intensity and severity of service
• Work with Inderdiciplinary team to evaluate patients and identify areas of improvement and Care. for outcome
• Working with LTAC, Rehab and home health for smooth Discharges.
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• Coordinated patient care plans with interdisciplinary teams for optimal outcomes.
• Conducted comprehensive assessments to identify patient needs and resources.
• Facilitated communication between patients, families, and healthcare providers.