Shannon McClasky
Sutherland Cardiology Clinic
Millington,TN
32
Years of experience
I work with SutherlandCardiology Group/ MLH Systems as part of the Outpatient Precert team.I have a wealth of experience with customer service, I am able to work on my own, self starter. 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 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.
Work History
PRECERTIFICATION SPECIALIST
5 Years 8 Months- 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.
- Nurtured strong professional relationships with insurance representatives, fostering a collaborative atmosphere during negotiations on behalf of patients.
- Documented authorization status accurately within electronic medical records and scheduling systems.
- Expedited treatment commencement by promptly acquiring authorizations for medically necessary services within required timeframes.
- Maintained strict adherence to HIPAA regulations by safeguarding confidential patient information during all aspects of the precertification process.
UTILIZATION REVIEW NURSE LPN
7 Years 5 Months- Reviewed patient admissions to determine medical necessity as directed by the MCG criteria
- 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
- 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.
- Coordinated concurrent utilization reviews with physicians, case managers, and interdisciplinary care teams.
- Documented utilization findings accurately in clinical records and review systems.
- Managed prior authorization requests and communicated coverage requirements to providers.
- Collaborated with payers to resolve authorization issues and maintain care continuity.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
- Implemented care plans for patient treatment after assessing physician medical regimens.
FLOOR LICENSED PRACTICAL NURSE
19 Years- Completed required forms and chart documentation, including recording vital signs, medications and other 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/ST
- 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
- Relevant Coursework: English, Math, Chemistry, Applicable Nursing courses
LPN Program
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
Timeline
PRECERTIFICATION SPECIALIST
Sutherland Cardiology Clinic
02.2021 - CurrentRead More
UTILIZATION REVIEW NURSE LPN
Methodist Le Bonheur Healthcare
09.2013 - 02.2021Read More
FLOOR LICENSED PRACTICAL NURSE
Methodist Le Bonheur Healthcare
08.1994 - 08.2013Read More
Tennessee College Of Applied Technology
LPN Program
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University Of Memphis
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Southwest Community
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