Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Susan Hampton, RN

Snellville,GA

Summary

Experienced utilization nurse with over three decades of nursing experience seeking opportunity in esteemed organization. Skilled in serving as liaison between medical professionals, patients, and families. Strong interpersonal and organizational skills, coupled with decision-making abilities, ensure effective communication and positive relationships. Specialize in crisis intervention, group facilitation, and collaboration within multidisciplinary teams. Proficient in adhering to Interqual and Milligan guidelines to optimize patient care coordination and enhance outcomes through streamlined processes and regulatory compliance.

Overview

24
24
years of professional experience
1
1
Certification

Work History

Utilization Review Nurse

HCA
03.2018 - Current
  • Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
  • Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
  • Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Manage approximately 15-20 calls from payers, ie, Cigna, UHC, Aetna, and other managed care third party companies. In addition to reviewing authorizations and denial faxes.

Appeals and Claims Nurse Consultant

Aetna, Inc.
06.2010 - 03.2018
  • Responsible for the review and resolution of clinical documentation, clinical complaints and appeals
  • Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria (Milliman or Interqual guidelines) and policies in line with regulatory and accreditation requirements for member and provider issues

UR and Nurse Care Manager: Telemonitoring

AMC Health
07.2016 - 06.2017
  • Responsible for the telephonic management of complex cases
  • Remotely assess patient’s health problems (COPD, HTN, CHF, and DM) and needs
  • Utilize the case management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care
  • Coordinated and analyzed sustainable person-centered care plans involving internal and external providers.

Home Health Nurse

Gentiva Home Health Care
11.2008 - 07.2010
  • After hours home health nurse admissions and triage
  • Intravenous infusions which included administration of IV antibiotics, TPN, inotropic cardiac drugs, PCA pain medications, enteral feedings, and wound care
  • Chronic disease education for diabetes, congestive heart failure, end stage renal disease, central lines, and port access and de-access

Utilzation Review/Case Manager

Humana, Inc.
11.2007 - 03.2010
  • Perform case management/utilization reviews for members with complex, chronic care needs
  • Conduct assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during the assessment
  • Assessed, evaluated psychosocial and medical needs of assigned patients
  • Consulted with health care team to assess, monitor, implement and evaluate patient care plan
  • Monitored all aspects of patient care: physical, mental, dietary and therapeutic
  • Maintained accurate charts, records and nursing reports
  • Facilitated dynamic and educational groups for patients
  • Coordinated discharge planning with treatment team for continuation of medical and psychiatric care

UtilizationReview/Utilization Review

Great West Healthcare (Cigna)
05.2004 - 02.2008
  • Assessed, coordinated, planned, and implemented case management services
  • Created individualized patient plan of care and address discharge needs

Case Manager/Utilization Review

DeKalb Medical Center
04.2001 - 05.2004
  • Case Manager of a 50 bed telemetry unit
  • Discharge planning
  • Utilization review
  • Assisting staff and physicians identifying patients’ needs
  • Use of Interqual to help patient meet inpatient and observation criteria

Education

Master of Nursing and Health Administration - Nursing Administration

University of Phoenix
Phoenix, AZ
01.2009

Bachelor of Science - Nursing

Georgia State University
Atlanta, GA
01.1986

Skills

  • Documentation and reporting
  • InterQual criteria
  • Utilization review
  • Records analysis
  • Microsoft 365
  • Insurance verification
  • Healthcare regulations
  • Managed care
  • Medicaid
  • Medicare

Certification

  • Registered Nurse, Georgia Board of Nursing
  • Registered Nurse, California Board of Nursing
  • Registered Nurse, Nevada Board of Nursing
  • Certified Case Manager, Expired 2012

Timeline

Utilization Review Nurse

HCA
03.2018 - Current

UR and Nurse Care Manager: Telemonitoring

AMC Health
07.2016 - 06.2017

Appeals and Claims Nurse Consultant

Aetna, Inc.
06.2010 - 03.2018

Home Health Nurse

Gentiva Home Health Care
11.2008 - 07.2010

Utilzation Review/Case Manager

Humana, Inc.
11.2007 - 03.2010

UtilizationReview/Utilization Review

Great West Healthcare (Cigna)
05.2004 - 02.2008

Case Manager/Utilization Review

DeKalb Medical Center
04.2001 - 05.2004

Master of Nursing and Health Administration - Nursing Administration

University of Phoenix

Bachelor of Science - Nursing

Georgia State University

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