Stephanie Oates
Inwood,WV
Summary
Accomplished Virtual Utilization Review Specialist, enhancing nursing satisfaction and retention. Expert in healthcare regulations and HIPAA compliance, with strong interpersonal communication skills. Demonstrated success in utilizing Milliman Criteria to optimize medical necessity evaluations and improve patient care standards. Reliable individual bringing 10 years of experience in healthcare environments. Maintains positive relationships with case managers and providers. Remains polished and calm under extreme stress.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Virtual Utilization Review Specialisty
Ensemble Health Partners
01.2023 - Current
- Performed admission reviews based for medical necessity based upon Milliman Criteria Guidelines specification.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Supervised and maintained all utilization review documentation through Epic.
- Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale by serving as Employee Engagement committee chair.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Utilization Review Nurse
Valley Health System
11.2014 - 12.2022
- Performed admission reviews based for medical necessity based upon Milliman Criteria Guideline specification.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Supervised and maintained all utilization review documentation through Epic.
- Served as subject matter resource, orienting several new employees and creating a new hire information packet.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Registered Nurse - Cardiac Interventional Holding
Valley Health System
02.2011 - 11.2014
- Contributed substantially to successful department JCAHO accreditation by consistently operating to highest standards of care.
- Advised patients and caregivers of proper wound management, discharge plan objectives, safe medication use, and disease management.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
- Evaluated patient histories, complaints, and current symptoms.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
- Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
- Managed patients recovering from invasive procedures.
- Monitored patient reactions after administering medications and IV therapies.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Recorded details regarding therapies to keep patient charts updated.
- Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
- Educated family members and caregivers on patient care instructions.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
Education
Bachelor of Science - Nursing
Shepherd University
Shepherdstown, WV05.2004
High School Diploma -
Keyser High School
Keyser06.2000
Skills
- Healthcare regulations
- Medicare Compliance
- HIPAA Compliance
- Utilization Management
- Medicare knowledge
- Medicaid knowledge
- Interpersonal and written communication
Certification
- Certified in MCG, obtained January 2024
Timeline
Virtual Utilization Review Specialisty
Ensemble Health Partners
01.2023 - Current
Utilization Review Nurse
Valley Health System
11.2014 - 12.2022
Registered Nurse - Cardiac Interventional Holding
Valley Health System
02.2011 - 11.2014
Bachelor of Science - Nursing
Shepherd University
High School Diploma -
Keyser High School
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