Patricia Pompilio

• Educated nursing staff on documentation standards and regulatory requirements for utilization review practices.
• Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
• Case review for member requests for increase in Consumer Directed Personal Care/Personal Care Assistance.
• Making determinations of medical necessity based on NFLOC score and tasking tool
• Notifying members of adverse determinations and appeal process
• Use of language line
• Maintaining Excel spreadsheet for caseload to assure UM timeframes are maintained.

Timely review of member requests to include (PCA, CDPAS, DME, high hour requests, home modifications) and all MLTC benefits.

Maintaining Excel Spreadsheets to track caseloads and maintain UM timeframes

Review of priority and expedited member requests

Prioritizing caseload based on timeframes

Making UM determinations and contacting members and providers

Case review for potential change in condition/need for reassessment

Collaboration with Case Management to ensure appropriate services

Determining medical necessity/Denial/Partial approvals for PCA/CDPAS requests

Review of high hour requests and collaboration with medical directors for determinations

Managing large caseload in fast paced enviornment

• Clinical Case Review for CDPAS/PCA hour requests using UAS NY Score and Time Tasking Tool
• Case review for DME requests
• Close collaboration with Care Managers for hour determinations and to obtain additional clinical information to make appropriate home care determinations
• Setting up and obtaining all information from Care Manager for increase in CDPAS and PCA hour requests, sending all clinical to nurse reviewer for final hour determination based on clinical information.
• Single Case Agreements
• Creating and updating Care Plans

• Clinical Case review of documentation for potential MLTC services and eligibility for services.

• Set up and created a Utilization Review Department
• Case review for increase or decrease in CDPAS/PCA member requests using UAS NY Scores and time tasking tool
• Assuring all documentation for CDPAS services was in place
• Managed Appeal requests and set up for secondary review.
• Managed Excel Spreadsheet of requests
• Managed temporary increase requests, sending email reminders to Care Managers
• Case review of high hour CDPAS/PCA cases
• Case review for DME items and high dollar requests such as ramps etc. Coordinating with contractors for specific home modification requests.
• Weekly meetings with Case Managers for case discussion, additional information to make a final determination
• Setting up and collaborating with UR team, UR assistant and medical director for weekly meetings with Care Manager to discuss requests for live in, 24-hour care for their members.
• Provided a thorough review of requests and assuring all information for member was received and appropriate decisions made based on clinical information provided.

• Provide precertification for all pending Orthopedic Surgeries for 7 different healthcare plans.
• Working and organizing a queue for daily reviews
• Used Milliman Guidelines to review Orthopedic cases for appropriateness and approvals
• Setting up cases for Medical Director review if not meeting Milliman Guidelines
• Case discussion with medical directors to make appropriate determinations for surgical procedures
• Gathering additional clinical information from providers
• Sending request for information letters
• Working closely with case manager assistants to assure all clinical documentation has been provided.
• Making determination calls to requesting Surgeons and their staff

• Provide precertification, concurrent review and retrospective reviews for designated health care services to ascertain medical necessity justification through the application of established criteria.
• Identify quality of care issues, request the medical record and refer the supervisor for review.
• Identify patient's needs by collecting in-depth clinical and psychosocial information through communication with the patient, treating physicians and other members of the treatment team.
• Assist in the coordination of an appropriate level of discharge planning.
• Provide case documentation in the Hudson Health Plan case record and update appropriately.
• Compile and analyze utilization management statistics to identify outliers or patients who may require case management intervention.
• Identify potential stop loss cases to present to supervisor for review.
• Prepare and maintain cost analysis reports when necessary.
• Negotiate and document reimbursement rates for health care services when necessary.
• Explore community resources and seek alternative delivery options when available.
• Identify and refer cases that require special consideration to the Hudson Plan Health Medical Director and or the Chief Medical Officer.
• Assist with the patient-centered and provider-based case management programs when necessary.
• Review pharmacy requests that require special consideration for "overrides".
• Monitor utilization management correspondence which include authorization and medically necessity denial letters.
• Act as a medical resource for the Case Manager Assistants.
• Interact with interdepartmental staff when necessary to ensure proper authorization and Payment.
• Participate with community agency activities as indicated.
• Participate in patient-centered and provider-based case management programs as needed.
• Comply with all applicable legislation/regulations and internal quality assurance standards.
• Participate in all other activities as required by the Hudson Health Plan Management.

• Clinical Documentation Specialist: performing concurrent chart review for
• Medicare Population for appropriate DRG assignment to ensure accurate DRG
• Assignment. Daily education for physicians and ancillary staff to promote
• Clear and accurate documentation within the medical record. Monthly JHACO
• Audits performed as well.

• Duties included educating a class of eight students on basic nursing skills, bed baths, vital signs, and documentation for a set patient assignment, as well as Accu check training, pre and post educational conferences.

• On site utilization review using Interqual criteria for local hospital, as well as telephonic review for several nearby hospitals, including in plan and out of plan facilities. Discharge planning as well as home care coordination with participating home care agencies

• Duties included RN staff nurse for emergency room and outpatient department clinics, staff medical surgical nursing as well as Charge Nurse for geriatric rehabilitative unit
• ED: EKG recording, interviewing veterans for urgent care needs, EMR admission and history form. Clinic: interviewing patients for routine PCP appointments and medication renewals
• Charge Nurse: Charge nurse for long term rehabilitation unit which included time keeping, overseeing nursing staff, daily assignments, weekly patient interdisciplinary meeting for discharge planning needs.