Open To Work
Hi, I’m
Vicki Love
Registered Nurse
Mont Belvieu
Work Preference
Summary
Detail-oriented Registered Nurse with over 30 years of experience in diverse care settings with the last 5 years in utilization management, specializing in precise clinical documentation interpretation. Skilled in translating complex data into actionable insights to determine medical necessity and regulatory compliance. Conducts clinical appeals reviews across multiple service categories and collaborates with medical directors and interdisciplinary teams to enhance workflows and maintain high patient care standards.
Overview
33
years of professional experience
Work History
United Health Care
Appeals Nurse M&R and E&I Appeals Pre-Service
05.2021 - Current
Job overview
- Conducted comprehensive clinical reviews of pre-service appeals to assess medical necessity and benefit coverage in accordance with applicable policies, regulatory requirements, and evidence-based clinical criteria.
- Demonstrated experience performing clinical appeals reviews across diverse service categories, including medical/surgical procedures, diagnostic imaging, DME and related supplies, specialty therapies/devices and other utilization management areas aligned to health plan medical policy.
- Translated complex clinical documentation into clear and concise findings to support medical necessity and benefit coverage in accordance with applicable policies, regulatory requirements, utilization management guidelines and evidence based clinical criteria.
- Analyzed medical records and provider documentation to produce accurate, well-supported appeal determinations, ensuring alignment with clinical guidelines.
- Collaborated with medical directors and interdisciplinary teams to gather clinical information and clarify case details.
- Maintained high productivity and quality standards while applying critical thinking and sound clinical judgment in decision-making.
- Prepared concise clinical documentation that effectively supported appeal determinations and met all audit requirements.
United Healthcare
RN Case Manager Community and State
09.2016 - 05.2022
Job overview
- Collaborated with patients and caregivers to develop tailored care plans.
- Developed person-centered care plans addressing chronic conditions, health promotion, and safety.
- Advocated for patients to ensure their needs were met effectively.
- Coordinated interdisciplinary care team to identify and address treatment plan barriers.
- Conducted comprehensive needs assessments to evaluate medical, functional, cultural, and socioeconomic factors, ensuring holistic care planning.
- Partnered with internal providers and community resources to implement tailored care plans, improving member outcomes and resource utilization.
- Supported members through health education, medication reviews, and referrals to community resources, enhancing member engagement and care access.
- Coordinated necessary member services, including home health and durable medical equipment.
- Maintained accurate records in electronic health systems for continuity of care.
Select Health Care Services
Home Health Administrator/Director of Nurses/Case Manager
01.1999 - 04.2015
Job overview
- Managed daily operations of home health services for diverse patient groups.
- Collaborated with interdisciplinary teams to coordinate comprehensive patient care plans.
- Assessed patient care plans for alignment with individual health requirements.
- Led nursing staff through mentorship and performance evaluations to promote growth.
- Streamlined operational efficiency by developing new policies and procedures.
- Ensured compliance with healthcare regulations through oversight of clinical operations.
- Monitored regulatory changes impacting home health service delivery.
- Implemented electronic medical records systems to enhance operational practices.
Acute Care Hospital
Registered Nurse Medical/Surgical, ER Unit
09.1993 - 06.1999
Job overview
- Assisted in emergency procedures during critical situations, ensuring timely and effective patient care.
- Provided patient care to diverse populations with various medical and surgical conditions.
- Assessed and prioritized patient needs, collaborating with interdisciplinary teams for individualized care plans.
- Monitored patient responses to treatments and medications, documenting observations and effectively communicating updates to the care team.
- Performed bedside procedures, including IV line insertion, catheter management, and wound dressing.
- Educated patients and families on disease processes and treatment options, empowering them with self-care strategies for better health outcomes.
- Documented patient care accurately in electronic health records systems.
Education
Lee CollegeBaytown, Texas
Associate Degree from Nursing
05-1993
University Overview
Skills
- Problem-solving and critical thinking
- Collaboration with cross-functional teams
- Effective communication skills
- Analytical thinking and clinical reasoning
- Translation of clinical documentation
- Data management expertise
- Familiarity with electronic health records
- Knowledge of medical coding systems
- Utilization management strategies
- Proficient in Microsoft applications, ATS, IQUE, InterQual, ETS, Knowledge Library, Doc360
- Adherence to medical policies and guidelines
- Disease management practices
- Managed care reimbursement knowledge
- Understanding of pre-acute and post-acute care
- Familiarity with physician office routines and documentation in electronic medical records
- Leadership capabilities
Timeline
Appeals Nurse M&R and E&I Appeals Pre-Service
United Health Care
05.2021 - Current
RN Case Manager Community and State
United Healthcare
09.2016 - 05.2022
Home Health Administrator/Director of Nurses/Case Manager
Select Health Care Services
01.1999 - 04.2015
Registered Nurse Medical/Surgical, ER Unit
Acute Care Hospital
09.1993 - 06.1999
Lee College
Associate Degree from Nursing