Samantha Arthurs
Pittsburgh,PA
Summary
Seasoned Registered Nurse with 19 years of diverse experience in clinical care, utilization management, and quality review. Skilled in evaluating clinical documentation, identifying workflow gaps, and standardizing processes. Leverages clinical judgment and data analysis to enhance clinical informatics and optimize EHR system usage.
Overview
1
1
Certification
3
3
years of post-secondary education
20
20
years of professional experience
Work History
Grievance Nurse
UnitedHealthcare
09.2024 - Current
- Provided subject-matter expertise for grievance processes; trained staff and facilitated virtual meetings to promote consistent workflows and documentation practices.
- Collaborated with internal departments, providers, and leadership to clarify clinical information and resolve concerns, ensuring timely case completion.
- Review clinical records and investigate member and provider grievances and appeals, synthesizing information into accurate case documentation and clinical summaries.
- Analyzed trends and conducted root-cause investigations to identify documentation gaps and process risks, enhancing clinical workflows.
- Maintain accurate, confidential records in accordance with HIPAA, CMS, DMHC, DHCS, and applicable state and federal requirements.
- Worked remotely to facilitate communication and collaboration with team members.
Clinical Reviewer / Case Management – UM Team Lead
Optum / UnitedHealthcare
07.2014 - Current
- Performed prospective, concurrent, and retrospective utilization reviews for Medicare Advantage and managed care populations, ensuring adherence to clinical documentation and established review criteria.
- Conducted chart audits to assess documentation quality and CMS compliance, coaching team members to enhance clinical review practices.
- Analyzed data to identify process trends, standardizing virtual workflows to improve consistency and operational efficiency.
- Remote
Rehab Clinical Liaison
Encompass Rehabilitation Hospital
08.2012 - 05.2019
- Educated staff on rehabilitation admission protocols, payer requirements, EMR systems, and clinical documentation practices to enhance compliance and streamline admissions.
- Reviewed clinical information and completed patient assessments to facilitate payer approvals using ICD-10 coding and InterQual criteria, ensuring access to necessary care.
- Oriented staff across multiple roles to establish consistent quality standards and documentation practices, fostering a unified approach to patient care.
- Facilitated orientation for staff to establish unified quality standards and documentation processes.
Clinical Nurse II – Med Surg Float Pool
West Penn Hospital / Forbes Regional Campus
06.2006 - 10.2012
- Delivered comprehensive nursing care across medicine, trauma, oncology, vascular, neurology, orthopedics, and rehabilitation units, adapting to diverse patient needs.
- Led the team as charge nurse and unit supervisor; mentored and precepted new nurses in clinical care and documentation practices.
- Participated in charting audits, infection prevention, and patient satisfaction committees, providing frontline clinical insights to enhance patient care processes.
Education
Bachelor of Science - Nursing
Penn State University
Diploma - Nursing
Citizens School of Nursing
Pittsburgh, PA 09.2004 - 06.2007
Skills
- HIPAA and regulatory compliance
- EHR and EMR navigation
- Chart audits
- Data review quality
- InterQual
- ICD-10
- Trend analysis
- Workflow optimization
- Process standardization
- User training
- Multidisciplinary collaboration
- Remote clinical operations
- Epic
- Meditech
- MCG
- ICD-10
Certification
- Registered Nurse | Pennsylvania, Kentucky, Ohio
- Basic Life Support
- Leadership Foundations Program | Completed
Timeline
Grievance Nurse
UnitedHealthcare
09.2024 - Current
Clinical Reviewer / Case Management – UM Team Lead
Optum / UnitedHealthcare
07.2014 - Current
Rehab Clinical Liaison
Encompass Rehabilitation Hospital
08.2012 - 05.2019
Clinical Nurse II – Med Surg Float Pool
West Penn Hospital / Forbes Regional Campus
06.2006 - 10.2012
Diploma - Nursing
Citizens School of Nursing
09.2004 - 06.2007
Bachelor of Science - Nursing
Penn State University