VICTORIA TOUCHSTONE

I perform utilization management services including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols.

• Supervised and maintained all utilization review documentation through Milliman and InterQual.
• Developed detailed plans based on broad guidance and direction.
• Complied with regulatory mandates by issuing notices and assisting with appeals.
• Obtain authorizations from multiple insurance carriers for various levels of care.
• Submitted cases for criteria failures and helped facilitate resolutions and approvals.
• Maintained 50 cases daily. Closed between $1 million to $3 million in authorized cases daily.

• Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
• Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
• Investigated and resolved issues affecting hospital operations and patient care.
• Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
• Participated in hospital committees to recommend quality improvement initiatives.
• Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.
• Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
• Managed from1-3 critical care patients daily