Tammy Newton
Wendell,NC
Summary
Compassionate Utilization Review Nurse with diversified experience in healthcare settings. Proficient in ensuring patient care services are medically necessary and within the parameters of prescribed protocols. Strengths include strong clinical judgment, critical thinking skills, and proficiency in using medical software for data analysis. Known for contributing to team success by promoting best practices in patient care management.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Utilization Review Nurse
WakeMed Hospital
Raleigh, NC
03.2021 - Current
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Analyzed data from patient surveys, interviews and other sources to assess healthcare service quality.
- Provided education to providers regarding utilization management processes and protocols.
- Analyzed utilization data to identify patterns and make recommendations for cost-effective care delivery.
- Identified opportunities for improvement within the utilization review process through data analysis.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Collaborated with case managers to facilitate timely discharge planning and transition of care.
- Attended conferences and training sessions related to utilization review topics such as best practices or new technologies.
- Coordinated with healthcare team to establish, enact and evaluate patient care plans.
- Educated healthcare providers on utilization review processes, criteria, and best practices.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Provided feedback to healthcare providers on clinical documentation improvement to support utilization review.
- Facilitated communication between payers, providers and patients concerning authorization issues or concerns.
- Monitored diet, physical activity, behaviors and other patient factors to assess conditions and adjust treatment plans.
- Coordinated with other departments within the organization regarding changes in policy or procedure implementation.
- Referred cases to secondary review for failure to meet criteria.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Ensured compliance with federal, state, and accreditation requirements related to utilization management.
- Documented all utilization review activities, findings, and decisions in patient records and databases.
- Interpreted and evaluated diagnostic tests to identify and assess patient's condition.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Case Manager
Amazing Kids of NC
Youngsville
12.2020 - 01.2025
- Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.
- Spoke to community groups to explain and interpret purposes, programs, and policies.
- Coordinated comprehensive care plans for clients to meet their individual needs.
- Linked clients with social services, health care providers and governmental agencies to help claim or reclaim individual autonomy.
- Counseled clients on available resources within the community that could help meet their needs.
- Monitored client progress through regular follow-ups and case reviews.
- Assisted individuals with eligibility for available benefits.
- Identified barriers to client success and developed strategies to overcome them.
- Advocated for clients by obtaining information regarding treatment options and clinical status.
- Conducted home visits to assess living conditions and support needs.
- Maintained up-to-date case records with case activity status.
- Provided referrals to appropriate health care providers or other community resources.
- Maintained confidentiality and adhered to professional ethics and standards.
Registered Nurse
WakeMed Hospital
Raleigh, North Carolina
01.2015 - 03.2019
- Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
- Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
- Developed and adapted individualized treatment plans according to patient recovery goals.
- Administered medications, tracked dosages and documented patient conditions.
- Administered oral, intramuscular and IV medications to patients and monitored responses.
- Trained and mentored new RNs on best practices, hospital policies and standards of care.
- Answered patient questions and provided take-home materials for further information.
- Coordinated care for up to 4 patients per shift.
Registered Nurse
PruittHealth
Raleigh, NC
05.2014 - 01.2016
- Educated patients and families on treatment strategies and at-home care.
- Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
- Developed and adapted individualized treatment plans according to patient recovery goals.
- Administered medications, tracked dosages and documented patient conditions.
- Answered patient questions and provided take-home materials for further information.
- Immunized patients against diseases such as influenza and pneumonia to protect vulnerable populations from serious illnesses.
- Cultivated working partnerships with patients and medical staff members, using feedback and clinical data to improve quality care and patient outcomes.
- Maintained personal and team compliance with medication administration standards and patient care best practices.
- Cared for patients in recovery from medical procedures by caring for wounds, monitoring vitals and managing pain.
Registered Nurse
Vidant Health
Greenville, NC
06.2014 - 12.2015
- Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
- Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
- Delivered direct patient care, including stabilizing patients and identifying treatment options.
- Treated patients using pharmacological and non-pharmacological treatment modalities to address various disorders, diseases and injuries.
- Maintained composure and efficiency during rapid response situation and emergency codes.
- Boosted patient outcomes by prioritizing nursing tasks and assignments and accurately reporting on each patient's status.
- Communicated with primary care physicians or emergency care providers to relay patient needs.
- Collected lab specimens, ordering and interpreting diagnostic tests and lab results.
- Participated in hospital-wide initiatives and committees to improve patient care, satisfaction and safety.
- Assessed patients in active drug and alcohol withdrawal and provided interventions to manage physical and psychological withdrawal symptoms.
- Updated physicians on patient test results and assisted in developing care plans.
- Used facility EMR system to update patient records, transmit prescriptions and transfer files.
- Delivered high-quality and compassionate treatment to all patients.
- Monitored and educated nursing students and externs on proper care procedures and prioritization strategies.
Education
Bachelor of Science - Nursing
University of North Carolina At Wilmington
Wilmington, NC12-2020
Associate of Applied Science - Nursing
Nash Community College
Rocky Mount, NC05.2014
Associate of Arts - Early Childhood Education
Trocaire College
Buffalo, NY05.1997
Skills
- Patient monitoring
- Medical screening
- Wound cleaning/care expertise
- Patient advocacy
- Electronic Health Records Management
- IV drug therapy management
- IV and venipuncture certified
- Patient Satisfaction and Process Improvement
- Diabetes management
- Removing stitches and staples
- Patient Management
- Patient Care
- Strong medical ethic
- Triaging patient concerns
- Medication and IV administration
- Clinical documentation
- Compliance monitoring
- Care coordination
- Patient education
- HIPAA compliance
- Utilization review
- Data analysis
- Regulatory compliance
- Care management
- Quality improvement
- Data entry
- Multitasking
- CCM certified
- Analytical and critical thinking
- Data management
- Time management
Certification
Basic Life Support (BLS) Certification, 01/2012, present
CCM Certification 2024, present
Timeline
Utilization Review Nurse
WakeMed Hospital
03.2021 - Current
Case Manager
Amazing Kids of NC
12.2020 - 01.2025
Registered Nurse
WakeMed Hospital
01.2015 - 03.2019
Registered Nurse
Vidant Health
06.2014 - 12.2015
Registered Nurse
PruittHealth
05.2014 - 01.2016
Bachelor of Science - Nursing
University of North Carolina At Wilmington
Associate of Applied Science - Nursing
Nash Community College
Associate of Arts - Early Childhood Education
Trocaire College
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