Shannon Hostetter
Alamosa,CO
Summary
Results-driven Registered Nurse with expertise in utilization review and healthcare compliance. Proven ability to analyze clinical data and collaborate with multidisciplinary teams to enhance patient care and optimize resource utilization.
Overview
5
5
years of professional experience
2
2
Certifications
Work History
Registered Nurse
UST Heatproof
Aliso Viejo, California
01.2025 - Current
- Reviewed patient records for medical necessity and appropriate care levels.
- Collaborated with healthcare teams to coordinate patient treatment plans.
- Analyzed clinical data to ensure compliance with regulatory standards.
- Facilitated communication between providers and insurance companies regarding approvals.
- Documented review findings in electronic health record systems accurately.
- Conducted audits of care plans to identify areas for improvement.
- Educated staff on utilization review processes and best practices.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Provided education to providers regarding utilization management processes and protocols.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions.
- Developed case management plans based on individual patient needs and eligibility criteria.
- Collaborated with staff members in group meetings to identify issues and find cost-effective solutions.
- Coordinated with other departments within the organization regarding changes in policy or procedure implementation.
- Communicated with external partners such as managed care organizations or vendors on a regular basis.
- Attended conferences and training sessions related to utilization review topics such as best practices or new technologies.
- Analyzed data from patient surveys, interviews and other sources to assess healthcare service quality.
- Performed discharge planning including referrals for post-acute care services when appropriate.
- Referred cases to secondary review for failure to meet criteria.
- Generated reports related to utilization management activities such as length of stay trends, denials rates.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Identified opportunities for improvement within the utilization review process through data analysis.
- Coordinated with healthcare teams to develop care plans that meet patient needs and insurance coverage.
- Participated in multidisciplinary team meetings to discuss patient care issues and utilization review findings.
- Reviewed and updated utilization review criteria and guidelines to reflect current standards of practice.
- Monitored patient admissions and discharges to optimize care coordination and resource utilization.
- Collaborated with case managers to facilitate timely discharge planning and transition of care.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Documented all utilization review activities, findings, and decisions in patient records and databases.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Performed pre-certification, concurrent, and retrospective reviews of inpatient and outpatient services.
- Ensured compliance with federal, state, and accreditation requirements related to utilization management.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Interpreted and evaluated diagnostic tests to identify and assess patient's condition.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Referred patients to specialized health resources or community agencies to furnish additional assistance.
- Monitored diet, physical activity, behaviors, and other patient factors to assess conditions and adjust treatment plans.
RN Case Manager
UST Heatproof
Aliso Viejo, California
07.2023 - 01.2024
- Coordinated patient care plans with multidisciplinary teams for optimal health outcomes.
- Assessed patient needs and developed individualized care strategies for diverse populations.
- Monitored patient progress and adjusted care plans based on evolving medical conditions.
- Educated patients and families on treatment options, medications, and health management.
- Advocated for patients' needs within healthcare systems to ensure comprehensive support.
- Documented patient interactions and care plans in electronic health record systems accurately.
- Collaborated with healthcare providers to streamline communication and enhance service delivery.
- Coordinated medical services between primary care providers, specialists, hospitals and outpatient clinics.
- Educated patients on disease prevention strategies, wellness promotion techniques and lifestyle modifications.
- Maintained accurate documentation of patient progress in the electronic health record.
- Actively participated in multidisciplinary rounds discussing complex cases with members of the healthcare team.
- Ensured compliance with regulatory standards concerning utilization review, ethical decision making and legal aspects of case management practice.
- Assessed patient's physical, mental, and psychosocial health status to develop individualized care plans.
- Provided emotional support and counseling to patients dealing with chronic illness or end-of-life issues.
Utilization Review Nurse
Friday Health Plans
Alamosa, Colorado
03.2021 - 07.2023
- Reviewed patient records for medical necessity and appropriate care levels.
- Analyzed clinical data to ensure compliance with regulatory standards.
- Facilitated communication between providers and insurance companies regarding approvals.
- Documented review findings in electronic health record systems accurately.
- Conducted audits of care plans to identify areas for improvement.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.
- Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions.
- Analyzed data from patient surveys, interviews and other sources to assess healthcare service quality.
- Referred cases to secondary review for failure to meet criteria.
- Reviewed and updated utilization review criteria and guidelines to reflect current standards of practice.
- Collaborated with case managers to facilitate timely discharge planning and transition of care.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Documented all utilization review activities, findings, and decisions in patient records and databases.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Performed pre-certification, concurrent, and retrospective reviews of inpatient and outpatient services.
- Ensured compliance with federal, state, and accreditation requirements related to utilization management.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Education
Bachelor of Science - Nursing
University of Colorado Colorado Springs
Colorado Springs, CO05-1999
Skills
- Utilization review
- Electronic health records
- Medical criteria application
- Patient data management
- Clinical documentation analysis
- Healthcare compliance
- Data interpretation
- Case management
- Team collaboration
- Solution identification
References
References available upon request.
Certification
Inter-Rater Reliability with InterQual Certificate
Closing
Thank you for considering my application. I look forward to the opportunity to learn more about the company and discuss how my qualifications and years of experience can contribute to the team's success. Further and more detailed experience is available upon request. I am eager to hear back from you.
Thank you.
Shannon Hostetter, BSN
Timeline
Registered Nurse
UST Heatproof
01.2025 - Current
RN Case Manager
UST Heatproof
07.2023 - 01.2024
Utilization Review Nurse
Friday Health Plans
03.2021 - 07.2023
Bachelor of Science - Nursing
University of Colorado Colorado Springs