Rachel Carpenter
Dayton
Summary
Dynamic Utilization Review Nurse at Humana with expertise in medical necessity determination and regulatory compliance. Proven track record in enhancing processes and ensuring quality assurance. Skilled in data analysis and time management, effectively collaborating with teams to drive improvements and optimize patient care outcomes. Recognized for empowering staff and fostering a culture of excellence. Adaptable professional with a quick-learning ability and a talent for adjusting to new environments. Skilled in rapidly acquiring new knowledge and applying it effectively. Driven by a passion for continuous learning and successfully navigating change.
Overview
17
17
years of professional experience
Work History
Utilization Review Nurse
Humana
Dayton
10.2021 - Current
- Educated healthcare providers on utilization review processes, criteria, and best practices.
- Documented all utilization review activities, findings, and decisions in patient records and databases.
- Collaborated in team meetings identify issues and find cost-effective solutions.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Identified opportunities for improvement in processes related to utilization management functions.
- Served as a resource for staff members' matters.
- Referred patients to care management when equipment was denied and needed additional assistance.
Team Manger
Acclaim Hospice
Dayton
01.2013 - 10.2013
- Held regular one-on-one meetings with employees to review performance and priorities and provide feedback.
- Recognized and rewarded team and individual achievements, boosting morale and motivation.
- Reviewed completed work to verify consistency, quality, and conformance.
- Conducted regular employee performance evaluations to offer constructive feedback and solutions to propel improvements and growth.
- Reviewed candidate resumes and scheduled and interviewed potential new hires.
- Partnered with upper management and HR to identify effective resolutions for employee relations issues.
- Provided guidance, coaching and mentoring to individual team members as needed to help them reach their full potential.
- Delegated work to staff, setting priorities and goals.
- Conducted regular meetings with staff to discuss progress on projects, provide updates on changes in policy or procedure, and address any issues that need to be addressed.
- Resolved customer inquiries and complaints requiring management-level escalation.
Team Manager
Hospice of Dayton
Dayton
01.2008 - 01.2013
- Conducted root causes analysis to develop corrective action plans.
- Reviewed completed work to verify consistency, quality, and conformance.
- Utilized project management software to track team tasks, deadlines, and accomplishments.
- Developed and implemented strategies to improve team performance.
- Facilitated weekly team meetings to discuss progress, address challenges, and plan future activities.
- Initiated training sessions and coached employees to develop effective staff.
- Recruited qualified candidates through job postings, interviews and referrals; evaluated resumes and applications; extended offers of employment.
- Resolved customer inquiries and complaints requiring management-level escalation.
- Managed daily operations of the team including scheduling shifts, assigning tasks, tracking attendance and approving time off requests.
- Partnered with upper management and HR to identify effective resolutions for employee relations issues.
Education
Associate of Science - Nursing
Sinclair Community College
Dayton OHBachelor of Science - Nursing
Indiana Weslyan University
Marion, INSkills
- Utilization review
- Medical necessity determination
- Regulatory compliance
- Data analysis
- Electronic health records
- Quality assurance
- Time management
Affiliations
- volunteer for a local animal rescue, like to garden, hike and spend time with family
References
References available upon request.
Timeline
Utilization Review Nurse
Humana
10.2021 - Current
Team Manger
Acclaim Hospice
01.2013 - 10.2013
Team Manager
Hospice of Dayton
01.2008 - 01.2013
Associate of Science - Nursing
Sinclair Community College
Bachelor of Science - Nursing
Indiana Weslyan University
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