Accomplished RN Case Manager and Utilization Review Nurse at Ballad Health System, adept in chronic disease management and care coordination. Leveraged multidisciplinary approaches and HIPAA compliance to enhance patient outcomes, demonstrating a keen ability for critical thinking and case evaluation. Excelled in utilizing clinical judgment to optimize healthcare service delivery, showcasing exceptional communication and organizational skills.
* Initial information sent to Insurance as a first level review is conducted to determine if admission is justifiable and reimbursable.
*Continued stay review to determine if each day is necessary and level of care appropriate
*Use of Milliman and Interqual criteria.
* Use of clinical judgement and critical thinking using past experience in ICU, CICU, Orthopedics, Trauma and Neuro.