Summary
Overview
Work History
Education
Skills
Certification
Acheivements
Additional Information
Timeline
Generic

Stacey Mesecher

Orlando,FL

Summary

Proficient and seasoned Utilization Management Registered Nurse with 10 years experience in inpatient concurrent and prospective reviews and discharge case management. Resilient active duty military spouse of 11 years.

I help healthcare companies effectively utilize healthcare dollars by using evidence based data and techniques to determine medical necessity and length of inpatient and alternative level of care stays. I am dedicated to building and maintaining respectful and professional healthcare provider relationships in order to find the best outcomes for members/customers.

Overview

23
23
years of professional experience
1
1
Certification

Work History

Inpatient Care Manager, Utilization Review Nurse

Optum, UnitedHealth Group
07.2013 - 06.2023
  • Continually reduced healthcare costs through efficient utilization review of medical necessity of concurrent initial acute inpatient hospital stays and prospective initial alternative level-of-care (ALOC) stays, such as Acute Inpatient Rehabilitation and Long-Term Acute Care Hospitalization; Evaluated medical guidelines, such as MCG, InterQual, Medicare Guidelines and benefit coverage to determine appropriateness of services.
  • Effectively evaluated for medical necessity of continued inpatient level-of-care stays and continued lower-level-of-care stays.
  • Used interdisciplinary team resources to plan and implement safe discharges and refer members to appropriate programs within their benefits.
  • Actively participated in weekly interdisciplinary/length of stay rounds to discuss level of care needs and discharge barriers.
  • Proactively searched for new ways to use Our United Culture of Integrity, Compassion, Relationships, Innovation and Performance
  • Completed required and voluntary UHC ICM courses, including Business Acumen; Participated in work groups
  • Dedicated to UnitedHealth Group’s mission, values, and Code of Conduct; devotion to the ethical principles of nursing.
  • Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
  • Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
  • Served as subject matter resource,
  • Supported organizational growth and development through effective collaboration with interdisciplinary teams focused on improving the quality, safety, and efficiency of healthcare delivery.
  • 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.
  • Devise or identify solutions for irregular requests and issues.
  • Supervised and maintained all utilization review documentation through proprietary software of CareOne and HSR.
  • Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
  • Promoted positive outcomes with proactive assessment of patients'' needs and development of targeted interventions to address identified barriers to recovery.
  • Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
  • Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
  • Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
  • Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
  • Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
  • Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
  • Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.

Registered Nurse/Floor LTACH

Select Specialty Hospital
02.2009 - 06.2013
  • Performed full spectrum of Registered Nursing functions needed in the Long Term Acute Care Hospital environment, including but not limited to: providing exceptional assessment skills while planning and delivering care for numerous patients including those on ventilators and/or having respiratory disorders; cardiac disorders including those with pacemakers, defibrillators, and telemetry; renal disorders (acute and chronic) including those on hemodialysis/peritoneal dialysis; complicated wounds with treatments, dressing and/or negative pressure wound therapy.
  • Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
  • Collaborated with interdisciplinary teams to develop comprehensive treatment plans for complex patients with multiple comorbidities.
  • Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
  • Enhanced patient satisfaction by providing compassionate, holistic nursing care that addressed physical, emotional, and spiritual needs.
  • Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
  • Provided support for patients'' families during difficult medical decisions or end-of-life care, serving as a liaison between the healthcare team and loved ones.
  • Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
  • Managed care from admission to discharge.
  • Advised patients and caregivers of proper wound management, discharge plan objectives, safe medication use, and disease management.
  • Maintained quality care and comfort for patients with heart failure, pulmonary hypertension, and other conditions.
  • Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
  • Facilitated patient transitions between different levels of care, ensuring continuity of services and minimizing disruptions in treatment plans.
  • Participated in ongoing professional development opportunities to stay current on best practices in nursing care and emerging trends in healthcare delivery.
  • Implemented evidence-based fall prevention strategies, resulting in a significant decrease in patient falls within the unit.
  • Monitored patient condition by interpreting and tracking EKG readings, identifying irregular telemetry readings and updating team members on changes in stability or acuity.
  • Organized and managed care of patients undergoing various therapies and procedures.
  • Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches.
  • Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.
  • Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
  • Monitored patient reactions after administering medications and IV therapies.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Evaluated patient histories, complaints, and current symptoms.
  • Managed patients recovering from medical or surgical procedures.
  • Provided skilled, timely and level-headed emergency response to critically-ill patients.

Registered Nurse Case Manager/LTACH

Select Specialty Hospital
02.2009 - 06.2013
  • Planned and implemented safe discharges for patients while following physician and interdisciplinary team guidance
  • Coordinated patient/family meetings with physicians and interdisciplinary team
  • Led and attended weekly interdisciplinary meetings to discuss treatment goals for patients
  • Built trusting relationships with physicians, insurance companies, community nursing facilities and hospitals
  • Initiated inpatient pre-certifications while providing clinical data to insurance companies; provided weekly commercial and Medicare guideline updates for continued stay day authorizations
  • Advocated and provided an open and safe environment for patients and families
  • Adhered to policy guidelines and followed leadership standards for quality.
  • Served as a key liaison between patients, families, and healthcare providers, fostering open communication and trust among all parties involved in the care process.
  • Evaluated the effectiveness of implemented interventions periodically, adjusting treatment plans as needed to promote optimal patient outcomes.
  • Collaborated closely with physicians to develop individualized treatment plans, supporting optimal patient outcomes.
  • Coordinated care conferences with interdisciplinary team members, ensuring all perspectives were considered in the development of comprehensive treatment plans.
  • Educated patients and families on available community resources, facilitating access to necessary support services.
  • Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
  • Streamlined discharge planning processes, ensuring a smoother transition for patients back to their homes or other facilities.
  • Managed support services and fostered communication among social workers, therapists, hospital staff, and patients.

Medical Assistant/Registered Nurse

Chung-Seng Lee, M.D., Gastroenterology, Internal Medicine
01.2000 - 01.2009
  • Performed full spectrum of nursing functions for gastroenterology and internal medicine practice
  • Accurately used ICD-9 and procedure codes to pre-certify and charge insurance companies for procedures/exams; educated patients on Medicare guidelines and criteria.
  • Documented vital signs and health history for patients in clinic and hospital environments.
  • Performed medical records management, including filing, organizing and scanning documents.
  • Called and faxed pharmacies to submit prescriptions and refills.
  • Scheduled appointments, registered patients, and distributed sample pharmaceuticals as prescribed.
  • Built strong relationships with patients through effective communication skills that foster trust in the clinic''s commitment to quality care.
  • Collected and documented patient medical information such as blood pressure and weight.
  • Assisted with routine checks and diagnostic testing by collecting and processing specimens.
  • Verified patient insurance coverage and collected required co-payments.
  • Obtained client medical history, medication information, symptoms, and allergies.
  • Ensured patient safety and comfort during examinations, effectively addressing concerns and answering questions.
  • Assisted physicians with minor surgeries, including preparing operating room and sterilizing instruments.
  • Maintained a safe and clean clinical environment by adhering to infection control guidelines and disposing of biohazardous waste properly.
  • Completed clinical procedures and gathered patient data for interpretation by physician.
  • Aided in accurate diagnoses by performing laboratory tests and preparing specimens for analysis.
  • Taught patients about medications, procedures, and care plan instructions.
  • Maintained strict adherence to infection control protocols by following proper sterilization techniques for medical equipment.
  • Answered telephone calls to offer office information, answer questions, and direct calls to staff.
  • Increased coding accuracy by diligently reviewing medical documentation and applying appropriate codes.
  • Reviewed patient charts to better understand health histories, diagnoses, and treatments.
  • Correctly coded and billed medical claims for various hospital and nursing facilities.
  • Prevented costly fines by ensuring adherence to HIPAA regulations when handling sensitive patient information.
  • Resourcefully used various coding books, procedure manuals, and on-line encoders.
  • Reduced claim denials by maintaining thorough knowledge of payer-specific requirements and guidelines.

Education

Associate of Science in Nursing -

Purdue University
01.2008

Skills

  • Utilization Review, Complex Discharge Case Management, Medical Records Management, MCG, InterQual, Medicare Guidelines, EMR, Microsoft Office, Proprietary Software, 65 WPM Typing, High level of Autonomy and Integrity
  • Insurance Experience, Knowledge and Billing, CPT 9-10, CPT, HCPCS, Medicare, Medicaid and Commercial Insurance Requirements
  • Precepting, SME, Continuing Education
  • Chronic Disease Management, Interdisciplinary Team Collaboration

Certification

  • Multi-State Registered Nurse (FL, RN 9358998)
  • Certified Case Manager (CCM)


Acheivements

  • Achieved effective to outstanding year-end performance reviews consistently; Reached outstanding status in all business goals while also exceeding expectations in my manager evaluation in 2023.
  • SME (subject-matter expert) for proprietary insurance software and MCG evidence-based guidelines.
  • CCM certification with 13+ years case management experience, focused on hospital discharges and lower-level-of-care transitions.
  • Achieved annual IRR score of 100 percent and NICM audit score of 99 to 100% consistently.
  • Well established, frequently sought after peer mentor who has formally trained numerous employees
  • Consistently hit productivity targets through effective organization and focus on work flow
  • Keen eye for quality assurance. Achieved high accuracy through proactive review of Job Aids/DESs/SOPs
  • Committed to building and maintaining trust and strong relationships with manager, peers, medical directors, facility contacts and members
  • Accountable for achieving personal developmental goals to improve job performance
  • Driven to improve productivity and efficiencies


Additional Information

detail oriented

love to be given an opportunity to learn more and grow as a nurse

Timeline

Inpatient Care Manager, Utilization Review Nurse

Optum, UnitedHealth Group
07.2013 - 06.2023

Registered Nurse/Floor LTACH

Select Specialty Hospital
02.2009 - 06.2013

Registered Nurse Case Manager/LTACH

Select Specialty Hospital
02.2009 - 06.2013

Medical Assistant/Registered Nurse

Chung-Seng Lee, M.D., Gastroenterology, Internal Medicine
01.2000 - 01.2009

Associate of Science in Nursing -

Purdue University

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