Shannon Mcclasky
Millington,TN
Summary
Self-motivated, decisive healthcare professional with proven bedside manner, clinical skills and critical thinking skills. Able to manage and document current conditions to effectively support patients and work within multidisciplinary healthcare team to enhance outcomes. Specialize in bedside patient care. I have had years of training new nurses, or students that worked on the floor. Using bedside nursing skills, outcomes coordinator knowledge, Cerner training and years of being a super user. I transition to Utilization review nursing and used my experiences to understand the MCG criteria and then translate what is needed to submit clinical to payors for precertification. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
29
29
years of professional experience
Work History
Precertification Specialist
Sutherland Cardiology Clinic
02.2021 - Current
- Coordinated referrals through insurance and other medical specialists and documented details in patient charts.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Evaluated patient histories, complaints, and current symptoms.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed prior authorization review of services requiring notification.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Utilization Review Nurse LPN
Methodist Le Bonheur Healthcare
09.2013 - 02.2021
- Reviewed patient admissions to determine medical necessity as directed by the MCG criteria
- Contacted insurance carriers to obtain authorizations for services delivered to patients
- Collaborated with Case Managers, leaders in group meetings to identify issues and find cost-effective solutions
- Participate in Daily observation meetings
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries
- Managed Proactive processes pertaining to denials and potential denials as outlined by insurance carriers
- Kept detailed documentation on all utilization reviews by using Morcare and MCG criteria
- Training new Utilization Review RNs MCG Criteria, use of the online portals, phone calls and faxes to payors
- How Each insurance plan has they own rules of submitting inpatient or observation
- Knowing which payor uses
- MCG criteria or Interqual
- Referred cases to secondary review for failure to meet Inpatient criteria
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
Floor Licensed Practical Nurse
Methodist Le Bonheur Healthcare
08.1994 - 08.2013
- Completed required forms and chart documentation, including recording vital signs, medications and other information
- Charted changes in patient conditions and discussed concerns with supervising healthcare provider
- Provided pre- and post-operative nursing care
- Administered prescribed medications and started intravenous fluids to address patient symptoms and underlying etiologies
- Medications with patients and families explaining what the medication is for and how it affects the body
- Checked in on patients at regular intervals to record food and fluid intake and output, taking measures to promote healthy levels as needed
- Observed strict confidentiality and safeguarded all patient-related information
- Made valuable contributions to interdisciplinary healthcare team on daily huddles with case management determining why pt remained in the facility, speaking with Physicians regarding concerns arranged consultations with PT/OT and ST
- Initiated admissions, transitions and discharges by communicating with colleagues as well as patients and family members
- Provided Cerner training to the staff with the first and second go live events, Superuser for Cerner
- Answered patient calls, identified issues and determined how best to provide assistance within parameters established by facility and supervisor
- Worked with the Outcome Coordinator and Covered as the OCC as needed, following CMS guidelines for Evidenced Based Practice
- Excel to communicate with Staff
- Worked with and as a Discharge Nurse
- Facilitated appointments, communication with Physicians on needs of the Patient
- Spoke with the patient, giving handouts and booklets as needed with sitting down with the patient or family and reviewed the discharge papers or booklets given
- Covered for the Unit Coordinator answering the call lights, relaying messages to nursing and medical assistants
- Communicated effectively with patients and loved ones to explain diagnoses, treatment options and procedures
- Helped patients complete bathing, dressing and eating.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Worked under registered nurses to care for patients and manage basic care.
- Took samples to complete diagnostic and routine assessment tests.
- Responded to patient requests with appropriate clinical and personal assistance.
- Delivered emotional support to patients and families during challenging times.
- Administered basic patient care and treatments by dressing wounds, treating bedsores, giving enemas and performing catheterizations.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
Education
No Degree -
Relevant Coursework: English, Math, Chemistry, Applicable Nursing courses
No Degree - Nursing
Relevant Coursework: English, Math, Chemistry, Applicable Nursing courses
LPN Program
04.1994
Skills
- Utilization review
- Continuous assessments
- Skilled in Cerner, Morcare, MCG, use of Evicore, Carelon, NIA, Availity,
- Some Excel, Word application use
- Submitting authorization with needed clinical, using nursing experience on what is important and needed to document primary diagnosis and comorbidities
- Understanding Length of stay Projections based on Diagnosis
- Precertification Processing
- Patient Eligibility Requirements
- Procedural Codes
- Diagnostic Procedures
- Outpatient Procedures
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Precertification Specialist - Sutherland Cardiology Clinic
02.2021 - Current
Utilization Review Nurse LPN - Methodist Le Bonheur Healthcare
09.2013 - 02.2021
Floor Licensed Practical Nurse - Methodist Le Bonheur Healthcare
08.1994 - 08.2013
Southwest Community - No Degree,
University Of Memphis - No Degree, Nursing
Tennessee College Of Applied Technology - , LPN Program
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