Summary
Overview
Work History
Education
Skills
Additional Information
Timeline
Generic

Dannette Jones

Destrehan,LA

Summary

Energetic individual offering 27 years' experience in reviewing compliance standards and auditing charts. Astute Utilization Review Nurse knowledgeable in medical data gathering, analysis and authorization obtainment.

Overview

30
30
years of professional experience

Work History

Utilization Review Specialist

Louisiana Children's Medical Center - UMC
New Orleans, LA
08.2022 - Current
  • Work with insurance companies and patients to determine best courses of action.
  • Determine medical necessity and cost-effectiveness of services through utilization review processes.
  • Apply medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
  • Collaborate with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
  • Review patient admissions to determine medical necessity as directed by McKesson/ Indicia criteria.
  • Refer cases to secondary review for failure to meet McKesson / Indicia criteria.
  • Contact insurance carriers to obtain authorizations for services delivered to patients.
  • Kept detailed documentation on all utilization reviews by using EPIC Medical Documentation system.
  • Collaborate with Interdisciplinary teams including discharge planners in group meetings to identify issues and find cost-effective solutions.
  • Manage facility policies and processes pertaining to denials and potential denials as outlined by insurance carriers.
  • Coordinate with healthcare team to establish, enact and evaluate patient care plans.
  • Maintain strict patient data procedures to comply with HIPAA laws and prevent information breaches.
  • Utilize computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.

RN Denial- Appeals

Elevance Health - Anthem
Indianapolis, IN
03.2015 - 08.2022
  • Determined medical necessity and cost-effectiveness of services through utilization review processes.
  • Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
  • Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
  • Reviewed patient admissions to determine medical necessity as directed by McKesson , MCG / Indicia criteria.
  • Managed policies and company processes pertaining to denials and potential denials as outlined by insurance carriers.
  • Maintained awareness of government regulations, health insurance changes and financing options.
  • Received , investigated and responded to formal appeals and member complaints .
  • Analyzed the denials of inpatient Hospital, Ambulatory ( OP ) , DME and Pharmacy authorizations at managed care company.
  • Prepare cases for review by independent secondary reviewer for medical necessity .
  • Formulate appeals determination letter including case summary , reason for appeals / upheld denial and determination reasoning.

RN Case Manager

Interim Louisiana State Hospital -UH
New Orleans, LA
11.2011 - 03.2015
  • Developed patient care plans, overall patient health assessments and evaluations.
  • Collaborated with physicians on patient medications, medical needs and performance.
  • Updated and maintained discharge plan of care with physician, members of healthcare team, patients and families.
  • Determined and coordinated appropriate level of care to meet individual patient needs.
  • Assessed and reviewed patients for discharge and planning and integrated services for patients requiring home care, home infusion and durable medical equipment (DME).
  • Collaborated with physicians during medical rounds, updated treatment plans and provided plan of care to patients and families.
  • Arranged placement of admissions and transfers in accordance with clinical standards and guidelines.
  • Obtained recommendations for inpatient or outpatient level of care by discussing cases with physician advisor.
  • Arranged placement of new patient admissions and transfers according to clinical standards and guidelines.
  • Secured insurance authorizations to inpatient rehabilitation facilities or long-term care placement.
  • Coordinated with vendors and suppliers and negotiated medical equipment and supply prices.
  • Coordinated home care, home infusion and durable medical equipment for continued medical treatment and services.
  • Liaised between injured workers and hospital staff to organize treatment and after-care services.

RN Supervisor 2

Interim LSU Hospital - Cardiac Unit
New Orleans, LA
07.2007 - 10.2011
  • Monitored infection control and critical incidents and made changes and improvements to processes where necessary.
  • Partnered with organizational and unit leaders to devise QA/QI initiatives, continuously improving delivery of care, patient outcomes and overall services.
  • Administered medications and treatments, monitoring patients for reactions and side effects.
  • Assessed patient needs, prioritized treatment, maintained patient flows and assisted physicians with non-invasive procedures.
  • Maintained thorough, accurate and confidential documentation in medical records.
  • Recorded patient condition, vital signs, recovery progress and medication side effects.
  • Provided patient and family health education focusing on self-management, prevention and wellness.
  • Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
  • Trained and mentored new RNs on best practices, hospital policies and standards of care.
  • Assessed and prepared patients for procedures, performing initial and ongoing patient assessments.
  • Collected lab specimens, ordering and interpreting diagnostic tests and lab results.
  • Conducted intake assessments with patients and relatives to gather case history.
  • Monitored patients after surgery, answered questions and provided home care strategies.
  • Assumed care for patients on 32 bed cardiac unit . Supervised nursing and ancillary staff, conducted in-services or new policies and procedures , New equipment , and New Hire / Annual trainings.
  • Completed initial and annual employee performance evaluates including monitoring of time and attendance.

Public Health Nurse

Department of Health and Human Services
Metairie, LA
04.2006 - 07.2008
  • Planned and coordinated patient and family teaching and health education.
  • Entered client records in centralized database for progress tracking.
  • Tested clients for common conditions and referred to other community resources based on specific needs.
  • Maintained up-to-date and comprehensive electronic and paper filing systems.
  • Collaborated with local health departments and other community partners.
  • Educated public regarding community health resources in correctional facilities, community centers and churches.
  • Provided patients with post-discharge follow-up and recommended available counseling programs.
  • Performed assessments for each individual case to determine best fit for materials and services.
  • Assessed clients' eligibility for federal and state benefits programs.

Clinical Coordinator RN

Medical Center Of Louisiana
New Orleans, LA
07.1995 - 08.2005
  • Conducted clinical interviews and assisted with hiring decisions for staff of 10-20
  • Facilitated orientation, competencies and skills validation processes for clinical and Ancillary.
  • Educated team members, patients and family members on care plans, medication regimes and protocols.
  • Administered oral, IV and intra-muscular medications and monitored patient reactions.
  • Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
  • Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
  • Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
  • Monitored diet, physical activity, behaviors and other patient factors to assess conditions and adjust treatment plans.
  • Conducted specified laboratory tests to help detect conditions and determine diagnosis.
  • Interpreted and evaluated diagnostic tests to identify and assess patient's condition.

Education

MBA -

University of Phoenix
Tempe, AZ
06.2017

Bachelor of Science - Nursing

Dillard University
New Orleans, LA
05.1995

High School Diploma -

G.W. Carver Senior High School
New Orleans, LA
05.1987

Skills

  • Skilled in EPIC, McKesson, Indicia, Maces, Facets, Microsoft Office ( including Outlook, Edge, Excel, Word, and One Note
  • Medication and IV administration
  • Geriatric treatment knowledge
  • Team management
  • IV drug therapy management
  • Staff Development and Precepting
  • Intake and discharge
  • Continuous assessments
  • Utilization review
  • Patient transfers and transitions
  • Appeals and Denials
  • Cardiac Services
  • Ambulatory Care

Additional Information

  • Djones@15114@gmail.com ( email)
  • 985-248-2500 ( Phone)

Timeline

Utilization Review Specialist

Louisiana Children's Medical Center - UMC
08.2022 - Current

RN Denial- Appeals

Elevance Health - Anthem
03.2015 - 08.2022

RN Case Manager

Interim Louisiana State Hospital -UH
11.2011 - 03.2015

RN Supervisor 2

Interim LSU Hospital - Cardiac Unit
07.2007 - 10.2011

Public Health Nurse

Department of Health and Human Services
04.2006 - 07.2008

Clinical Coordinator RN

Medical Center Of Louisiana
07.1995 - 08.2005

MBA -

University of Phoenix

Bachelor of Science - Nursing

Dillard University

High School Diploma -

G.W. Carver Senior High School

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Dannette Jones