Rebekah Ortmann, BSN, PHN, RN
Ventura,CA
Summary
Dedicated and experienced utilization review nurse with sixteen years of experience assessing medical necessity, ensuring compliance with healthcare regulations, and optimizing patient care while controlling costs. Skilled in case review, insurance authorizations, and collaborative care planning. Seeking to leverage expertise in clinical assessment and utilization management to support efficiency and quality outcomes in a healthcare organization.
Overview
15
15
years of professional experience
1
1
Certification
Work History
RN Senior Medical Management
Anthem Blue Cross
07.2021 - Current
- · Ensure medically appropriate, high-quality, cost-effective care by assessing medical necessity, interpreting benefits, and managing care products
- · Verifying member eligibility and coordinating benefits with other primary payers. Managing members with dual enrollment in the Medicare and the California Medicaid program
- · Coordinate care with facilities and providers, working closely with medical directors to ensure accuracy in claims payment and appropriateness of care
- · Conduct reviews for pre-certification in the inpatient and outpatient setting, as well as out-of-network requests with redirection to in-network care when possible. Ensure compliance with regulatory agency requirements, APLs, medical policies and MCG criteria.
- · Facilitate member care transitions through the healthcare continuum
- · Participate in interdepartmental teams and projects including process improvement and job aide management.
- · Educate and support new staff with one-on-one teaching in a virtual environment. Compile training templates and material for various review types. Provide feedback for improvement to team members during training
- · Coordinate transplant care for California Medicaid patients, conduct patient record reviews, and collaborate with facilities and IPAs for capitated member care. Interpretation of Division of Financial Responsibility documents with outreach to the IPA for any discrepancies
- · Verify and update member requests with appropriate ICD-10 codes and CPT codes, notifying providers and facilities of updates when necessary
- · Engage in collaborative communication with a diverse multidisciplinary team comprised of: Physicians, Case Management, Continued Stay Review, CCS, Grievances and Appeals, Compliance, Contracting, Claims, and Intake
- · Proficient in Microsoft Office including Teams, Outlook, Word, OneNote and Excel.
Quality Improvement Registered Nurse
Ventura County Health Care Agency
03.2019 - 07.2021
- Perform chart audits and reports for primary care, child health, obstetric care.
- Implemented quality improvement initiatives to enhance patient care outcomes
- Analyzed data to identify areas for improvement and develop action plans
- Collaborated with interdisciplinary teams to implement evidence-based practices
- Monitored compliance with quality standards and regulations
- Provided education and training to staff on quality improvement practices
- Participated in quality improvement committees and meeting
Senior Registered Nurse Hospital
Ventura County Health Care Agency
09.2009 - 03.2019
- Supervised and mentored junior nursing staff
- Collaborated with healthcare team members to ensure quality patient care
- Participated in quality improvement initiatives and training programs
- Assessed patient conditions and developed care plans
- Educated patients and their families on health management and treatment plans
Education
BSN - Nursing
Channel Islands University
Camarillo, CA06.2017
ADN - Nursing
Ventura Community College
Ventura, CA05.2009
Certification
- RN, Registered Nurse, CA, 752972, 01/27
- PHN, Public Health Nurse, PHN554502, 01/27
Skills
- Strong clinical background and knowledge of medical terminology, disease processes, and treatment modalities. (10+ years)
- Proficiency in utilization management principles, including medical necessity criteria and reimbursement guidelines. (10+ years)
- Excellent communication and interpersonal skills, with the ability to collaborate effectively with diverse stakeholders. (10+ years)
- Analytical mindset and attention to detail, with the ability to critically evaluate medical documentation and treatment plans. (10+ years)
- Familiarity with electronic health record (EHR) systems and utilization review software. (10+ years)
- Commitment to continuous learning and professional development in the field of healthcare administration and utilization management. (10+ years
Timeline
RN Senior Medical Management
Anthem Blue Cross
07.2021 - Current
Quality Improvement Registered Nurse
Ventura County Health Care Agency
03.2019 - 07.2021
Senior Registered Nurse Hospital
Ventura County Health Care Agency
09.2009 - 03.2019
BSN - Nursing
Channel Islands University
ADN - Nursing
Ventura Community College
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