TALEIA POWELL, RN
Greenwood,IN
Summary
Compassionate and patient-centered health care professional with extensive experience in clinical care coordination, patient advocacy, regulatory compliance, and healthcare operations. Expertise includes call center operations, home care operations, utilization review, appeals and grievances, pharmacy benefit management, and market access. Adept at identifying and addressing patient needs using evidence-based practices to ensure safety and enhance outcomes. Known for strong teamwork and adaptability to meet evolving healthcare needs, with expertise in trend review and process improvement.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
Medical Behavioral Hospital of Indianapolis
07.2024 - 12.2024
- Supported data-driven decision-making by regularly analyzing trends in resource utilization, identifying opportunities for improvement, and implementing best practices.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
- Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
- Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
- Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
- Increased staff efficiency by providing ongoing education on proper documentation techniques necessary for accurate claims processing.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Participated in performance improvement initiatives designed to enhance service delivery while maintaining fiscal responsibility.
- 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.
- Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
- Supported organizational growth and development through effective collaboration with interdisciplinary teams focused on improving the quality, safety, and efficiency of healthcare delivery.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
Clinical Reviewer
1st Choice Healthcare (AmeriHealth Caritas)
03.2023 - 01.2024
- Reviewed prior authorization requests for home accessibility durable medical equipment for completeness and appropriateness.
- Conducted prescriber outreach to obtain clinical information required for MD determinations, if not on file.
- Located in-network contractors to conduct home assessments and submit work orders for proposed installations.
- Utilized established criteria to review equipment installation proposals received from in-network contractors.
- Processed repair requests.
- Notated client management system with pertinent information regarding review status and closed out service requests as required.
- Drafted determination correspondence to both patient and provider.
- Used department guidelines and parameters to maintain consistency and compliance with plan policies and procedures.
- Managed time efficiently in order to complete all tasks within deadlines and turn around times.
Appeals & Grievances Coordinator
1st Choice Healthcare (AmeriHealth Caritas)
10.2022 - 03.2023
- Conducted initial outreach calls in response to appeal service requests.
- Educated patients on the appeal process and set expectations.
- Drafted written correspondence throughout appeal process.
- Scheduled in-person, telephonic, and videoconferencing meetings between patients and appeal & grievance panel members.
- Maintained updated case notes in client management system.
- Remained knowledgeable regarding company policies, procedures and current developments relating to the grievance & appeal process.
- Managed time efficiently in order to complete all tasks within deadlines and turn around times.
- Collected data concerning patient-initiated external reviews.
Appeal Nurse Specialist
LASH GROUP; AMERISOURCEBERGEN
03.2020 - 07.2021
- Reviewed patient medical records and utilized clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
- Utilized pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.
- Used client approved clinical articles and searched for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
- Prepared feedback to clients and participated in client meetings.
- Received, documented, investigated and coordinated appeals.
- Interpreted payer guidelines and policies from a clinical perspective.
- Drafted, submitted and tracked action on appeals letters, reconsideration and re-determination requests and other communication with medical payers on behalf of providers and patients.
- Interpreted clinical information, performed searches for relevant articles and assists the customer through education and clear communication.
- Tracked the status of outstanding appeals and trending appeals successes to help develop internal appeal strategies for specific payers.
- Worked off a task list to ensure timelines and customer commitments are met.
- Supported the management team on program initiatives.
- Performed tele-health duties as dictated by program needs.
Utilization Management Review Nurse
EXPRESS SCRIPTS
03.2016 - 12.2018
- Reviewed traditional prior authorizations, step-therapy requests, formulary and benefit exclusion requests and quantity requests for multiple clients, plans and/or carriers while abiding by compliance, quality and productivity standards.
- Evaluated clinical documentation to determine appropriateness of services.
- Approved requests per established criteria.
- Drafted rationales for denials and forwarded said denials to the pharmacist/Medical Director for final review.
- Acted as a liaison between clients, patients and patient care advocates to provide guidance on clinical criteria.
- Served as subject matter resource regarding specialty and high touch medications.
Education
Associate of Applied Science - Registered Nursing
Medtech College
Indianapolis, IN10.2014
Skills
- Familiarity with Epic, Wellsky, Jiva, Siebal, and Salesforce CRM
- Interqual
- Managed Care
- Medicare/Medicaid/Medicaid Waiver Programs
- LTSS
- Utilization Management
- Prior Authorization, Concurrent Stay, and Retrospective Review
- Appeals & Grievances
- Discharge Planning
- Benefit Verification
- Determining eligibility for patient assistance and copay programs
- Patient education regarding prescribed therapies
- Injection Training
- Adverse Event Reporting
- Care Planning
- Microsoft Office Suite Proficiency
- Telephonic nursing; working in a telephone queue
- Ability to work autonomously and as part of a team
- Ability to learn quickly and adapt to a changing environment
- Ability to manage multiple concurrent tasks; good organizational skills
- Attention to detail; ability to focus for long periods of time on detailed information
- Analytical and critical thinking
- Excellent oral and written communication skills
- Problem solving skills
Additional Information
- Indiana RN Compact License; #28218473C
- Indiana Health & Life Insurance License; #3618559
- Basic Life Support (BLS) Certification; American Heart Association
Certification
- AHIP Medicare + Fraud, Waste, And Abuse (MFWA) Online Course
Timeline
Utilization Review Nurse
Medical Behavioral Hospital of Indianapolis
07.2024 - 12.2024
Clinical Reviewer
1st Choice Healthcare (AmeriHealth Caritas)
03.2023 - 01.2024
Appeals & Grievances Coordinator
1st Choice Healthcare (AmeriHealth Caritas)
10.2022 - 03.2023
Appeal Nurse Specialist
LASH GROUP; AMERISOURCEBERGEN
03.2020 - 07.2021
Utilization Management Review Nurse
EXPRESS SCRIPTS
03.2016 - 12.2018
- AHIP Medicare + Fraud, Waste, And Abuse (MFWA) Online Course
Associate of Applied Science - Registered Nursing
Medtech College
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