Nyga Halford, ASN, RN
Baton Rouge,LA
Summary
Dependable Smart Utilization Review Nurse with over 21 years of nursing experience considered critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare guidelines. Known for having great rapport with providers and insurance carriers. Knowledgeable in admissions, stay reviews and pre-service reviews.
Overview
22
22
years of professional experience
Work History
Registered Nurse Inpatient Surgery
Our Lady of the Lake Hospital
08.2021 - 09.2023
- Provide complex clinical assessments for care for Pre/Post Operative and Medical Surgical Patients
- IV therapy, assess vital signs, administer IV fluids/Antibiotics and medication administration, utilize electronic medical devices, wound care, patient/family teaching and education, and provide overall patient care
- Document patient care and status, while maintaining internal guidelines and external standards
- Software: Epic, Oracle, Microsoft teams/Word/Excel/PowerPoint, Kronos.
Nurse Medical Management I AR PASSE, Arkansas
Anthem, Summit Community Care
02.2020 - 11.2021
- Conduct 15 - 20 reviews per day by applying applicable criteria, medical policy, and member eligibility, benefits, and contracts while maintaining NCQA score of 94-97 percent.
- Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Medical Management I AR PASSE, Arkansas Medicaid
HealthCare Support Staffing, Summit Community Care
11.2019 - 02.2020
- Conduct reviews by applying applicable criteria, medical policy, and member eligibility, benefits, and contracts
- Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
UM Clinical Nurse Reviewer
AmeriHealth Caritas
04.2019 - 11.2019
- Reviewed 12-15 inpatient admissions, outpatient services/surgeries, and personal care services reviews per day to assure appropriate level of care and medical necessity utilizing InterQual Criteria and Louisiana Medicaid Policies
- Reviews admissions through on-site and telephonic review
- Provides patient and provider education
- Maintains interdisciplinary relationships with medical directors, case managers, and licensed social workers
- Data entry, including assessments, authorizations, and reviews
- Utilizes Microsoft teams, JIVA, Facets, and McKesson software.
- Enhanced interdisciplinary communication by collaborating with healthcare providers to discuss case findings and develop optimal care plans.
- Conducted in-depth research on emerging medical trends and best practices, sharing findings with colleagues to inform clinical decision-making processes.
- Reduced hospital readmission rates by identifying trends through comprehensive case reviews and recommending interventions.
- Improved patient care quality by conducting thorough clinical reviews and providing evidence-based recommendations.
- Increased efficiency in review process by streamlining workflows and implementing time-saving strategies for data collection and analysis.
- Contacted providers, state agency offices and applicants to obtain information and records needed to conduct comprehensive clinical review of case and final determination.
- Adhered to strict timelines for case completion while maintaining high level of accuracy and attention to detail during review process.
- Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
- Managed caseload efficiently while maintaining strict confidentiality of sensitive information per HIPAA regulations.
- Exhibited strong analytical skills when interpreting complex medical records to evaluate patient care outcomes against established benchmarks.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Acted as team leader in group projects, delegating tasks and providing feedback.
- Worked well in team setting, providing support and guidance.
- Resolved problems, improved operations and provided exceptional service.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
Medical Review Nurse
Blue Cross Blue Shield of Louisiana
09.2017 - 02.2019
- Performed thorough review of group, non-group, self-funded, State health plan, and Federal Employee Program claims and medical information for utilization and medical necessity according to specific contract provisions and medical policy
- Assisted claim processors through daily screening of pending claims and medical records
- Provided instructions, documentation, and prepared cases to be reviewed by medical director.
Prior Authorization Nurse Reviewer
Louisiana Healthcare Connections, Centene Corporation
07.2012 - 06.2017
- Louisiana Medicaid
- Reviewed and authorized urgent authorizations, inpatient admissions, outpatient services, and personal care services for level of care and medical necessity utilizing InterQual Criteria
- Acted as clinical resource to referral staff, assisted in referral process
- Maintained NCQA audit scores between 92% and 96%
- Participated in interdisciplinary meetings with medical directors, case managers, social workers, and other involved parties
- Utilized Trucare, Microsoft Word, Powerpoint, Excel software.
- Enhanced interdisciplinary communication by collaborating with healthcare providers to discuss case findings and develop optimal care plans.
Conducted in-depth research on emerging medical trends and best practices, sharing findings with colleagues to inform clinical decision-making processes.
Reduced hospital readmission rates by identifying trends through comprehensive case reviews and recommending interventions.
Improved patient care quality by conducting thorough clinical reviews and providing evidence-based recommendations.
Increased efficiency in review process by streamlining workflows and implementing time-saving strategies for data collection and analysis.
Contacted providers, state agency offices and applicants to obtain information and records needed to conduct comprehensive clinical review of case and final determination.
Adhered to strict timelines for case completion while maintaining high level of accuracy and attention to detail during review process.
Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
Managed caseload efficiently while maintaining strict confidentiality of sensitive information per HIPAA regulations.
Exhibited strong analytical skills when interpreting complex medical records to evaluate patient care outcomes against established benchmarks.
Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
Acted as team leader in group projects, delegating tasks and providing feedback.
Worked well in team setting, providing support and guidance.
Resolved problems, improved operations and provided exceptional service.
Assisted with day-to-day operations, working efficiently and productively with all team members.
Prior Authorization Nurse Reviewer
Molina Medicaid Solutions
07.2011 - 07.2012
- Louisiana Medicaid
- Performed prior authorization reviews via EPA (Electronic Prior Authorization), fax, and emergency phone request
- Utilized Medicaid criteria to determine medical necessity of requested services
- Referred prior authorizations to department physician.
Education
Associate of Science - Nursing (ASN)
Excelsior College
Albany, NY10.2018
Practical Nurse Diploma - Practical Nursing
Louisiana Technical College (LPN)
Baton Rouge, LA05.2002
Skills
- Clinical Assessment
- Utilization Review
- Medical Documentation
- Critical Thinking
- Communication Skills
- Time Management
- Problem-Solving
- Computer Proficiency
- Healthcare Regulations
- Interdisciplinary Collaboration
- Attention to Detail
- Patient education and counseling
- McKesson Interqual, EPIC, Trucare, Paradon, FACETS use
- Microsoft Office
- Care Plan Development
- HIPPA regulatory compliance
Affiliations
ACLS American Heart Association
BLS American Heart Association
Additional Information
- Nyga Halford, ASN, RN – Baton Rouge, LA License and Certifications: Active Multistate Registered Nurse License, #203650, Expires 01/31/2026.
Timeline
Registered Nurse Inpatient Surgery
Our Lady of the Lake Hospital
08.2021 - 09.2023
Nurse Medical Management I AR PASSE, Arkansas
Anthem, Summit Community Care
02.2020 - 11.2021
Medical Management I AR PASSE, Arkansas Medicaid
HealthCare Support Staffing, Summit Community Care
11.2019 - 02.2020
UM Clinical Nurse Reviewer
AmeriHealth Caritas
04.2019 - 11.2019
Medical Review Nurse
Blue Cross Blue Shield of Louisiana
09.2017 - 02.2019
Prior Authorization Nurse Reviewer
Louisiana Healthcare Connections, Centene Corporation
07.2012 - 06.2017
Prior Authorization Nurse Reviewer
Molina Medicaid Solutions
07.2011 - 07.2012
Associate of Science - Nursing (ASN)
Excelsior College
Practical Nurse Diploma - Practical Nursing
Louisiana Technical College (LPN)
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