Sandra DeGryse
Missoula,MT
Summary
Professional Utilization Review Nurse with 12 years experience in utilization management; majority of experience in review of emergency department admissions using InterQual criteria to determine most appropriate level of care to ensure compliance with federal and commercial payor requirements.
Overview
19
19
years of professional experience
1
1
Certification
Work History
RN CASE MANAGER - ADMISSIONS - Evenings / Remote
Providence St. Patrick Hospital
02.2018 - Current
- Works autonomously in remote setting completing approximately 30 clinical reviews nightly of emergency department admissions for determination of medical necessity at inpatient, observation and outpatient levels of care using InterQual criteria
- Communicate with physicians as needed for discussion of any discrepancy in admission status
- Escalate cases to Physician Advisor for recommendation of appropriate level of care when criteria is not met
- Submit initial authorization request to various commercial payors and compile EMR documents for payor review according to required specifics of each individual insurance company
- Follow company policies and procedures to comply with Medicare guidelines
UTILIZATION REVIEW NURSE
Allegiance Benefit Plan Management
01.2016 - 01.2018
- Soley responsible for review of behavioral health admissions and continued stay reviews as they pertained to specific level of care; inpatient psychiatric, chemical dependency, intensive outpatient, and residential rehabilitation
- Review and interpret medical records to establish medical necessity based on Milliman Care Guidelines (MCG) for initial certification and continued stay reviews for med-surg, obstetric, SNF and Acute Rehabilitation hospitalizations
- Identify cases not meeting established criteria and prepare for escalation to Medical Director for appropriate determination
CARE REVIEW CLINICIAN II – BEHAVIORAL HEALTH
Molina Healthcare Inc.
06.2012 - 12.2015
- Processed and managed behavioral health authorizations and concurrent reviews for psychiatric inpatient admissions for entire length of stay according to company policy as well as CMS guidelines by use of InterQual
- Consistently maintained company's standard of an average length of stay of 8 days or less for assigned caseload
- Maintained quality audit scores of ≥ 98% as well as expected department productivity goals
CHARGE NURSE – BEHAVIORAL HEALTH
Havenwyck Hospital
03.2006 - 03.2012
- Provided direction, motivation, and leadership to team of nurses and support staff in position of Charge Nurse in a 150 bed adult psychiatric hospital setting
- Provided direct care to a diverse population of adult psychiatric patients using the nursing process to address both physical and psycho-social needs of patient
- Completed comprehensive nursing assessments of patients with varying degrees of mental illness
Education
Associate Degree in Nursing -
Oakland Community College
Bloomfield Hills, MISkills
- Utilization review
- InterQual criteria
- Documentation and reporting
- Records analysis and data extraction
- Microsoft Word, Excel, Outlook
Certification
Valid Registered Nurse (Compact State) License
Timeline
RN CASE MANAGER - ADMISSIONS - Evenings / Remote
Providence St. Patrick Hospital
02.2018 - Current
UTILIZATION REVIEW NURSE
Allegiance Benefit Plan Management
01.2016 - 01.2018
CARE REVIEW CLINICIAN II – BEHAVIORAL HEALTH
Molina Healthcare Inc.
06.2012 - 12.2015
CHARGE NURSE – BEHAVIORAL HEALTH
Havenwyck Hospital
03.2006 - 03.2012
Valid Registered Nurse (Compact State) License
Associate Degree in Nursing -
Oakland Community College
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