Tiffany Camille Cox

• Performed admission reviews for medical necessity based upon Interqual criteria and hospital guidelines.

• Provided feedback, and assistance to other members of the healthcare team regarding appropriate use of resources and timely follow -thru with the plan of care.
• Maintained communication with outside vendors for care coordination and manage length of stay. Sent referrals thru the CarePort
• Completed initial and ongoing assessments of patients and families to determine and address individual home and post acute needs.

• Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
• Participated in daily rounds with treatment team for patient needs and reviewed medical records for updated documentation for discharge goals and plan.
• Performed initial and concurrent reviews and escalated any cases not meeting criteria to Medical Director.
• Provided clinical to insurance companies for case authorization and managed denials with team for timely resolve.

Travel Case Manager for hospitals in Texas, New Mexico and Florida

• Assessed and reviewed patients for discharge and coordinated post acute placement , home infusion, home health, and dialysis.
• Precepted new employees, providing guidance for InterQual, communication and referral systems.
• Participated in daily rounding with physicians, nursing, physical therapy and social work to coordinate care to meet needs of patients, documenting progress for team.
• Performed initial, concurrent and retrospective reviews for medical necessity and level of service. Reviewing observation cases and escalating as needed.
• Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care

• Performed prior authorization review of services requiring notification.
• Submitted cases for criteria failures and helped facilitate resolutions and approvals.
• Obtained authorizations from multiple insurance carriers for various levels of care.
• Performed performance reviews and interviewed candidates for utilization review roles.
• Worked with leadership team for process improvement.
• Maintained knowledge of applicable federal and state regulatory requirements, including TDI, CMS,DOL, HHSC and NCQA standards.

• Advocated for patients by communicating care preferences to practitioners, verifying in network choices and identifying insurance coverage limitations.
• Collaborated with physicians and outside vendors for post treatment home care to help prevent return hospitalizations.
• Reviewed patients admissions for medical necessity as directed by plan guidelines and InterQual criteria and escalating as needed to physician advisor.

• Enhanced patient satisfaction by collaborating with interdisciplinary teams to develop individualized care plans, ensuring appropriate level of care.
• Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
• Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
• Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.