Tammie Clark LPN
Edgewood,WA
Summary
Experienced Licensed Practical Nurse with a robust background in utilization review and managed care, spanning over two decades. Specializes in prior authorization processes and has extensive knowledge of Medicaid and Medicare systems. Executes detailed medical reviews to guarantee members receive necessary care promptly, adhering to productivity benchmarks and contractual obligations. Proven ability to thrive in dynamic, high-pressure settings while managing multiple tasks effectively.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Physician of Southwest Washington-Olympia, WA
UM Nurse Associate
06.2023 - 12.2024
- Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria
- Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care
- Collaborated with consulting physicians regarding care of patients.
Utilization Nurse Associate-Remote
Aetna Better Health Pennsylvania-Philadelphia, PA
06.2008 - 10.2022
- 14 years Managed care/Utilization Review experience
- Utilized clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
- Responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times.
- Gathered clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
- Communicates with Medical Directors and providers and other parties to facilitate care/treatment.
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
- Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation / information.
Medicare Clinical Review Specialist LPN
04.2005 - 03.2008
- Responsible for conducting high priority medical record reviews to ensure compliance, accurate coding, and appropriate billing. Specialty areas included: E/M, Multiple Surgery Files, and Outpatient Surgery Files. As a designated Recovery Audit Contractor (RAC) for Medicare, performed retrospective medical records and claims audit services under a direct contract with the Centers for Medicare and Medicaid Services (CMS) Worked independently to meet deadlines and manage time sensitive issues. Performed Medicare Paid claim analysis reviewing multiple records including medical necessity and correct diagnosis and procedure coding forms.
- Utilized nursing knowledge and experience to determine medical necessity. Assisted in the design and documentation of protocols to audit Medicare paid claims data.
Education
Certification -
Copiah Lincoln Community College
Natchez, MS01.1993
Associate of Applied Science - Computer Programming
Copiah Lincoln Community College
Wesson, MS01.1985
Skills
- Proficient with Microsoft Office applications
- 17 years Managed care experience LPN/LVN with current unrestricted state licensure (10 years)
- NCQA Standards (10 years)
- Medical Records review (10 years)
- Utilization Management (10 years)
- ICD-10 (10 years)
- Utilization review (10 years)
- Managed Care (10 years)
Certification
- Licensed Practical Nurse - WA 1998-Current
Timeline
Physician of Southwest Washington-Olympia, WA
UM Nurse Associate
06.2023 - 12.2024
Utilization Nurse Associate-Remote
Aetna Better Health Pennsylvania-Philadelphia, PA
06.2008 - 10.2022
Medicare Clinical Review Specialist LPN
04.2005 - 03.2008
Associate of Applied Science - Computer Programming
Copiah Lincoln Community College
Certification -
Copiah Lincoln Community College
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