CANDICE S. BROWN

• Serve as a team lead for the Clinical Assessment Review Experts team, providing day to day guidance and oversight
• Provide end to end project leadership for clinical review initiatives, coordinating clinical and operational stakeholders to ensure timely delivery and defined outcomes
• Conduct InterQual based utilization and level of care reviews across all lines of business
• Review and analyze complex medical records to support medical necessity determinations and policy compliance
• Collaborate with clinical and operational partners to promote consistency, accuracy, and quality outcomes
• Lead clinical audit and case review initiatives evaluating utilization management programs, medical policies, and clinical decision frameworks
• Manage high impact clinical chart review projects to assess the quality and consistency of medical necessity determinations
• Partner with Medical Directors and leadership to investigate utilization trends, identify root causes, and support targeted improvements
• Serve as a subject matter expert in the application of InterQual and nationally recognized clinical guidelines
• Analyze clinical and utilization data to identify gaps and develop evidence based recommendations to improve utilization patterns
• Identify and escalate gaps in InterQual criteria to the appropriate review teams for evaluation and updates
• Prepare clear, executive ready summaries of audit findings to support remediation efforts and quality improvement initiatives

• Supervise nursing operations and staffing in skilled nursing and long-term care setting
• Ensure compliance with CMS, State, and Joint Commission requirements
• Manage admissions, discharges, and change-of-condition response
• Planned and implemented staff education for quality patient care outcomes

• Facilitated national delegation remediation initiatives across all lines of business (M&R, E&I, C&S, and SNP) for over 140+ delegated groups
• Reviewed audit findings and corrective-action plans for regulatory alignment
• Tracked remediation progress and compliance metrics
• Project Management: Revamped SNP remediation program for delegated groups.
• Analyzed and interpreted detailed reports/trending issues and presented to Delegation Oversight Committee.
• Monitored compliance with remediation activities against relevant process requirements (state/federal regulations, CMS, and NCQA)
• Utilized process driven approach to identify root cause and process improvement activities to reduce potential risk.
• Experience with writing standard operating procedures
• Results driven: Facilitated remediation for regulatory program audits and tracked improvement until completed.

• Provided clinical oversight across skilled nursing and rehabilitation facilities
• Supported staff orientation and regulatory documentation requirements
• Planned, implemented, evaluated, and revised patient care plans based upon ongoing needs
• Participated in multi-disciplinary care planning and communicated plan of care to other team members and patient/patient representative.
• Managed IV/PICC line therapy; Wound Vac care and monitoring; medication administration.
• Responsible for coordinating admissions/discharges
• Nurse educator/trainer for new staff
• Administered injections, prescribed medications, wound care, and treatments per MD orders with accurate documentation

Medical Claims Review RN (Employer & Individual) 06/2021-09/2022

Preservice Review Nurse (Medicare & Retirement) 6/2014-06/2021

• Analyzed and assessed utilization management processes for preservice and claims to uphold standards of medical necessity and benefit accuracy.
• Audited delegate files for compliance with clinical standards and payer policy
• Reviewed ICD-10, CPT, and HCPCS coding accuracy and documentation integrity
• Performed Medicare & Retirement (M&R), Employer & Individual (E&I), Medicaid, SNP, Exchange, and Oxford chart audits of internal and external delegates which requires interpretation of CMS, state and federal mandates, NCQA guidelines, applicable benefit language, and consideration of relevant clinical information.
• Served as subject matter expert (SME) in multiple lines of business (M&R, E&I, Medicaid)
• Trainer/mentor for new clinical quality review nurses.
• Performed oversight of national delegate case files by conducting audits for compliance with regulatory guidelines (e.g., NCQA, state Medicaid contracts, Clinical Practice Guidelines, LCD, NCD, MCG, InterQual) and tracked trending concerns.
• Extensive experience with utilization management, prior authorization case review, and clinical claims management.