Rick Crawford
Spokane,WA
Summary
Utilization review nurse with extensive experience in reducing healthcare costs through strategic resource management and analytical expertise. Proficient in InterQual and MCG criteria, ensuring adherence to quality improvement and regulatory standards. Committed to enhancing patient care outcomes through effective collaboration with healthcare teams.
Overview
24
24
years of professional experience
Work History
Utilization Management Nurse Consultant
Aetna
Hartford, Connecticut
05.2025 - Current
- Conducted comprehensive reviews of medical necessity for various procedures.
- Maintained accurate documentation of utilization management activities and decisions.
- Assessed the necessity of requested treatments or services by comparing diagnosis-related group data against accepted criteria for quality assurance.
- Utilized computer systems such as EMRs and claims processing systems for research purposes related to utilization management activities.
- Analyzed medical records, clinical guidelines, policies and procedures to identify opportunities for improvement in healthcare services delivery.
- Documented all utilization management activities in accordance with departmental policies and procedures.
- Performed utilization review and concurrent care management services to ensure appropriate use of resources and compliance with regulatory requirements.
- Reviewed documentation from physicians, nurses, therapists and other health professionals to determine appropriateness of admission or continued stay.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Referred cases to secondary review for failure to meet criteria.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
UTILIZATION REVIEW NURSE
Physican of Southwest Washington
Olympia, WA
03.2023 - 10.2024
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Provided expert advice on medical necessity criteria and evidence-based practices, enhancing organizational decision-making in utilization review nursing.
- Processed cases for criteria failures, facilitating resolutions and approvals to support patient care.
- Achieved cost savings by efficiently utilizing resources and identifying unnecessary treatments or procedures.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
UTILIZATION REVIEW NURSE
Community Health Care of Washington
Olympia, WA
02.2018 - 03.2022
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Conducted prior authorization reviews for required services.
- Provided expert advice on medical necessity criteria and evidence-based practices, enhancing utilization review processes.
- Facilitated resolutions and approvals by submitting cases for criteria failures.
- Achieved cost savings by efficiently utilizing resources and identifying unnecessary treatments or procedures.
UTILIZATION REVIEW NURSE
Premera Blue Cross Of Washington
Spokane, WA
02.2015 - 01.2018
- Utilized resources efficiently and identified unnecessary treatments to reduce healthcare costs.
- Maintained accurate documentation of utilization review activities to ensure compliance with regulations and accreditation standards.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Reviewed prior authorization requests for services requiring notification to facilitate timely approvals.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
STAFF NURSE
RN Network
Boca Raton, FL
11.2013 - 12.2014
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Monitored patients' conditions, reporting changes in physical presentation, appearance, and behavior to physicians to inform treatment decisions.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Collaborated with physicians, pharmacists and therapists to deliver quality, evidence-based care.
- Coordinated patient care by initiating and implementing plan of care, ensuring continuity and clarity in discharge instructions.
- Acted as a patient advocate, ensuring their needs were met and their rights protected throughout their healthcare journey.
- Built strong rapport with patients and families, fostering trust and open communication to support care during challenging times.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Improved patient satisfaction scores by providing empathetic, compassionate care to diverse populations.
STAFF NURSE, CASE MANAGER, UNIT MANAGER
St Lukes Rehabilitation Institute
Spokane, WA
11.2001 - 10.2013
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Monitored patients' conditions and reported changes in presentation and behavior to facilitate timely treatment discussions with physicians.
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
- Conducted thorough assessments of clients' situations, identifying issues, goals, and necessary interventions.
- Monitored ongoing cases closely, adjusting case management strategies based on evolving circumstances.
- Enhanced communication between clients and providers through consistent follow-ups and detailed progress updates, improving care coordination.
- Ensured compliance with regulations and standards through regular audits, staff education, and policy updates.
- Resolved conflicts among team members quickly to maintain a positive working environment conducive for continued excellence in patient care.
- Oversaw RNs, LPNs, nursing aides, medical clerks and support staff and performed staffing scheduling duties.
- Managed budgetary constraints through careful resource allocation, cost control measures, and fiscal responsibility practices.
- Addressed clinical issues promptly to mitigate risks in patient care and improve operational efficiency in the unit.
- Assisted in development and implementation of policies, procedures, and regulations for unit operations.
- Developed strong working relationships with physicians, nurses, therapists, and ancillary staff for cohesive unit functioning.
- Optimized staffing levels by monitoring unit needs and making data-driven adjustments to scheduling as necessary.
- Increased staff retention rates with supportive leadership techniques, mentoring programs, and positive work environment initiatives.
- Promoted a culture of safety within the unit by enforcing strict adherence to protocols, guidelines, and infection control measures.
- Implemented evidence-based practices within the unit to enhance overall quality of care provided to patients.
- Participated actively in committee meetings to contribute insights from a Unit Manager perspective, influencing hospital-wide decisions and policies.
- Improved patient satisfaction with timely and accurate communication between patients, families, and medical professionals.
- Contributed to hospital-wide quality improvement initiatives by identifying areas of opportunity within the unit and implementing best practices.
Education
High School Diploma -
Thompson Falls High School
Thompson Falls, MT06-2000
Associate of Science - Nursing
Spokane Community College
Spokane, WASkills
- Utilization review
- InterQual Criteria
- Milliman Guidelines
- Utilization Management
- Case Management
- Clinical assessment
- Direct Patient Care
- Patient Condition Monitoring
- Monitoring Vital Signs
- Medication Administration
- Intravenous therapy
- Wound Care
- Discharge Planning
- Blood collection
- Quality Improvement
- Records analysis
- Documentation And Reporting
- Accurate Documentation
- HIPAA Compliance
- Critical Thinking
- Problem-Solving
- Clinical judgment
- Time Management
- Task Prioritization
- Multitasking
- Team Collaboration
- Teamwork and Collaboration
- Team delegation
- Active Listening
- Patient Education
- Patient communication
- Infection Control
- Professionalism
- Attention to Detail
- Student Precepting
- Multitasking Abilities
- Problem-solving abilities
- Documentation
- Multitasking
- Problem-solving abilities
- Multitasking Abilities
- Documentation
- Professionalism
Timeline
Utilization Management Nurse Consultant
Aetna
05.2025 - Current
UTILIZATION REVIEW NURSE
Physican of Southwest Washington
03.2023 - 10.2024
UTILIZATION REVIEW NURSE
Community Health Care of Washington
02.2018 - 03.2022
UTILIZATION REVIEW NURSE
Premera Blue Cross Of Washington
02.2015 - 01.2018
STAFF NURSE
RN Network
11.2013 - 12.2014
STAFF NURSE, CASE MANAGER, UNIT MANAGER
St Lukes Rehabilitation Institute
11.2001 - 10.2013
High School Diploma -
Thompson Falls High School
Associate of Science - Nursing
Spokane Community College