Theresa Cortese
Myrtle Beach,SC
Summary
Highly skilled in utilization review and case management, with a track record of minimizing unnecessary treatments and ensuring regulatory compliance. Committed to advocating for patient care while optimizing resource utilization. Known for exceptional communication skills and attention to detail, driving effective collaboration with interdisciplinary teams to enhance patient outcomes and satisfaction. Committed to advocating for patient care while optimizing resource utilization.
Utilizes clinical judgement to assess and recommend appropriate treatment plans.
Overview
40
40
years of professional experience
Work History
Utilization Review Nurse
Capital District Physicians Health Plan
Albany, NY
07.2007 - 04.2026
- Conducted comprehensive reviews of medical necessity for outpatient services.
- Led interdisciplinary meetings to discuss complex cases and establish coordinated care strategies.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
- Collaborated with co-workers and medical director to identify solutions for irregular requests and issues.
- Supported data-driven decision-making by regularly analyzing trends in resource utilization, identifying opportunities for improvement, and implementing best practices.
- Conducted thorough evaluations of medical necessity for procedures, leading to optimal resource utilization.
- Increased patient satisfaction by advocating for necessary patient care and services.
- Collaborated with physicians to clarify treatment plans, ensuring alignment with evidence-based practices.
- Collaborated with healthcare providers to ensure compliance with clinical guidelines and policies.
- Reduced unnecessary medical costs, ensuring treatments met established medical guidelines and policies.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Educated family members and caregivers on patient care instructions.
- Evaluated treatment plans for appropriateness, ensuring alignment with established care protocols.
- Developed training materials to enhance staff understanding of utilization review processes.
RN Case Manager
Empire Blue Cross
Albany, NY
02.2002 - 06.2007
- Coordinated comprehensive care plans for diverse patient populations to enhance health outcomes.
- Collaborated with interdisciplinary teams to streamline case management processes and improve service delivery.
- Monitored patient progress, adjusting treatment plans based on clinical assessments and feedback.
- Educated patients and families on disease management strategies to promote self-care and adherence.
- Facilitated communication between providers and patients to ensure continuity of care and resource utilization.
- Analyzed complex cases to identify barriers to care, developing targeted interventions for resolution.
- Provided emotional support to patients coping with chronic illness or end-of-life decisions.
- Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
- Educated patients and families on available community resources, facilitating access to necessary support services.
- Reduced hospital readmission rates through effective case management and patient education on self-care techniques.
- Promoted adherence to treatment plans by conducting regular follow-up calls and providing ongoing support to patients.
- Advocated for patients'' rights and preferences, working diligently to align care with individual values and goals.
- Improved patient satisfaction scores by providing timely follow-ups and addressing concerns promptly.
- Streamlined discharge planning processes, ensuring a smoother transition for patients back to their homes or other facilities.
- Educated patients and caregivers on healthcare protocols and processes.
- Mentored new nursing staff, facilitating a faster learning curve and increased overall team efficiency.
- Navigated regulatory requirements effectively, ensuring proper documentation and compliance with relevant laws and guidelines.
- Developed strong relationships with patients and their families, providing support and education on health management.
- Educated patients, family members, and caregivers on patient care instructions, medication side effects, and course of care.
Home Health Nurse
Visiting Nurses Association of Albany
Albany, NY
09.1992 - 02.2002
- Administered medications and treatments according to care plans.
- Assessed patient health status and documented findings accurately.
- Collaborated with interdisciplinary teams to coordinate comprehensive patient care.
- Developed individualized care plans based on patient needs and preferences.
- Educated patients and families on disease management, medication safety and at-home healthcare strategies to promote self care and safety.
- Documented patient vitals, behaviors, and conditions to communicate concerns to their healthcare providers.
- Provided physical assessments, medication, and chronic disease management to home health patients.
- Delivered high-quality in-home nursing services, maintaining a safe and comfortable environment for patients.
- Coordinated with multidisciplinary healthcare team members to implement comprehensive treatment plans to support patient needs.
- Served as a reliable resource for families seeking guidance on navigating complex healthcare systems and advocating for their loved ones'' needs.
- Teaching on effective infection control measures within the home setting, reducing risk of illness transmission among family members.
- Provided emotional support and kind companionship to patients and families to increase overall wellness.
- Enhanced patient recovery rates through diligent monitoring of vital signs, medication administration, and wound care.
- Managed patient medical records accurately and confidentially, ensuring compliance with HIPAA regulations.
- Optimized patient comfort by addressing individual physical, emotional, spiritual needs during end-of-life care.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Managed patients recovering from medical or surgical procedures.
- Administered different therapies and medications in line with physician orders and treatment plan.
- Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
- Identified early warning signs of patient deterioration or complications, promptly notifying physicians to adjust treatment plans accordingly.
- Conducted regular follow-up visits to monitor patient progress and make adjustments to care plans as needed.
- Implemented best practices to improve patient outcomes and satisfaction levels.
- Developed strong rapport with patients and families, fostering trust and open communication.
- Monitored patient reactions after administering medications and IV therapies.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
Staff Nurse
NursefindersMedical Staffing
Albany, NY
10.1988 - 09.1992
- Administered medications and treatments per physician orders to ensure patient safety and compliance.
- Monitored vital signs and documented patient progress to maintain accurate health records.
- Collaborated with multidisciplinary teams to develop and implement tailored care plans for patients.
- Educated patients and families about disease management and post-discharge care instructions.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
- Implemented medication and IV administration, catheter insertion, and airway management.
- Collaborated with physicians, pharmacists and therapists to deliver quality, evidence-based care.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, medication side effects, and management and lifestyle options.
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Demonstrated excellent time management skills while juggling multiple priorities in a fast-paced environment.
- Educated patients on self-care management, empowering them to take an active role in their overall health and wellbeing.
- Acted as a patient advocate, ensuring their needs were met and their rights protected throughout their healthcare journey.
- Assisted physicians with diagnostic procedures, ensuring accurate results for optimal treatment planning.
- Reduced medication errors through meticulous charting and double-checking dosages.
- Managed complex wound care, utilizing advanced techniques to promote healing and prevent infection.
- Evaluated the effectiveness of care plans regularly, making adjustments as needed based on individual patient needs and progress toward goals.
- Collaborated with interdisciplinary team members for comprehensive patient assessments and treatment plans.
- Evaluated patient histories, complaints, and current symptoms.
Staff Nurse
Veterans Administration Medical Center
Albany, NY
09.1987 - 10.1988
- Conducted comprehensive assessments, ensuring accurate documentation of patient health records.
- Ensured compliance with healthcare regulations, maintaining high standards of safety and quality care.
- Developed strong rapport with patients and families, fostering trust and open communication during challenging times.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Directed patient care by initiating and following through with plan of care, continuing care, and discharge instructions.
- Developed and implemented individualized patient care plans for optimal outcomes.
- Participated in regular staff meetings to share best practices, address challenges, and foster collaboration among team members.
- Promoted a culture of safety by strictly adhering to infection control measures and reporting any potential hazards or concerns.
- Exhibited strong critical thinking skills when assessing complex medical situations and determining appropriate interventions.
- Provided exceptional pre-and post-operative care, reducing recovery times and complications for surgical patients.
- Coordinated patient discharge planning to provide post-discharge patient care, promoting healing and recovery.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Recorded details regarding therapies to keep patient charts updated.
- Implemented care plans for patient treatment after assessing physician medical regimens.
High Risk Antepartum Staff Nurse
Albany Medical Center Hospital
Albany, NY
11.1985 - 09.1987
- Monitored vital signs and fetal health for high-risk antepartum patients.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
- Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
- Performed triage on incoming patients and determined severity of injuries and illnesses.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Educated family members and caregivers on patient care instructions.
- Administered medications and treatments following established protocols.
- Collaborated with multidisciplinary teams to develop patient care plans.
- Educated patients and families on high-risk pregnancy management strategies.
- Implemented evidence-based practices to enhance patient outcomes and safety.
- Trained and mentored junior nursing staff in antepartum care techniques.
- Conducted comprehensive assessments to identify potential complications early.
- Utilized evidence-based practices to inform decision-making processes in the management of high-risk pregnancies.
- Served as an advocate for patients'' needs within the healthcare team, promoting optimal treatment plans tailored to each individual case.
- Reduced complications for high-risk pregnancies with thorough assessments and individualized care plans.
- Assisted physicians during procedures and examinations, contributing to efficient and accurate diagnoses for high-risk patients.
- Promoted a supportive and inclusive environment by providing emotional support to patients from diverse cultural backgrounds experiencing high-risk pregnancies.
- Contributed to higher patient satisfaction scores by delivering exceptional bedside manner while addressing concerns and answering questions about high-risk pregnancies.
- Enhanced patient care by closely monitoring high-risk antepartum patients and providing timely interventions.
- Implemented appropriate interventions in response to fetal distress or maternal complications during antepartum care.
- Collaborated with multidisciplinary teams to optimize patient outcomes during high-risk pregnancies.
- Maintained detailed documentation of patient progress, ensuring effective handoffs between shifts and team members.
- Administered medications and treatments as prescribed, ensuring patient safety and comfort during hospital stays.
- Developed strong relationships with patients, fostering trust and open communication throughout their care journeys.
- Decreased patient anxiety through clear communication of medical information, treatment plans, and addressing uncertainties related to high-risk pregnancy situations.
- Responded to emergency situations such as pre-eclampsia, early labor, and fetal distress.
- Monitored patient reactions after administering medications and IV therapies.
- Evaluated patient histories, complaints, and current symptoms.
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
Education
Bachelor of Science - Registered Nurse
Albany Medical Center School of Nursing
Albany, NYSkills
- Documentation and reporting
- Utilization review/prior authorization
- Physician consultations
- HIPAA compliance
- Discharge planning
- Needs assessment
- Communication
- Teamwork and collaboration
- Attention to detail
- Active listening
- Adaptability and flexibility
Timeline
Utilization Review Nurse
Capital District Physicians Health Plan
07.2007 - 04.2026
RN Case Manager
Empire Blue Cross
02.2002 - 06.2007
Home Health Nurse
Visiting Nurses Association of Albany
09.1992 - 02.2002
Staff Nurse
NursefindersMedical Staffing
10.1988 - 09.1992
Staff Nurse
Veterans Administration Medical Center
09.1987 - 10.1988
High Risk Antepartum Staff Nurse
Albany Medical Center Hospital
11.1985 - 09.1987
Bachelor of Science - Registered Nurse
Albany Medical Center School of Nursing