Wendy Ayers

Execution of comprehensive utilization review strategies across a 5-facility healthcare system, overseeing a team of 85+ utilization review and denials professionals

• Successfully merged 5 clinical utilization review teams into one centralized department under the revenue cycle management department of Inova
• Created further revenue cycle synergies when leadership added the clinical denials and appeal team to my purview
• Collaborate with C-Suite and senior leadership to align revenue cycle goals with the organization's mission, resulting in improved patient care quality and resource allocation
• Design and implement standardized utilization review processes creating workflow and employee efficiencies focused on an increase in compliance with regulatory guidelines and revenue
• Utilize data analytics and reporting tools to monitor key performance indicators and utilization patterns, driving data-driven decision-making for process enhancement
• Foster strong interdepartmental relationships by collaborating with clinical departments, case management, and revenue cycle teams, resulting in streamlined communication and coordination of patient care plans
• Achieve improvement in overall team performance through mentorship, training, and performance evaluation initiatives
• Present utilization review strategies and outcomes to executive leadership, contributing to informed decision-making and strategic planning.

Highly experienced in all aspects of Case Management processes, procedures, and workflows. Led a team of over 40+ UR Nurses and CMAs to ensure accurate patient care while achieving optimal financial returns.

• Active participant in multiple Case Management, IHS, and Finance meetings including - High Dollar, Denials management, VIP Projects, Centralized Scheduling, UM committee, CFB, MCG, and Contracts/JOCs
• Conduct performance reviews, oversee scheduling and payroll, perform audits, set up training, and monitor analytics
• Provide strategic direction and oversight of day-to-day operations including LOS management, denials management, and optimizing reimbursement while maximizing the patient's provider benefits
• Work closely with Physician Advisors to develop and implement system-wide education programs for the UR teams, including biweekly Boot camps, developing training materials, and orientation/onboarding
• Process Improvement Projects include: Lipos/Wintex, Hysterectomy Coding, Medicare IP Only list, NICU level of care, and standardization/centralization of work documents and workflows
• Concrete understanding of state and federal regulatory requirements affecting care coordination services specifically, CMS, HIPAA, and PHI.
• Developed comprehensive staff training programs to enhance employees'' understanding of utilization review principles and practices.
• Identified and communicated customer needs to supply chain capacity and quality teams.

• Determine medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines for all hospital units including psych
• Coordinated with multidisciplinary teams to optimize patient care and eliminate delays which improved patient flow and length of stay
• Educated staff on documentation requirements and best practices to reduce denials
• Collaborated with physician advisors, medical staff, and payors to ensure proper authorization for hospital services rendered
• Evaluated treatment options, created treatment plans, and advised doctors on cost-effective discharge planning options
• Acted as a liaison between patients and healthcare professionals to explain processes to patients, relay important medical information, and connect patients with resources, teams, and specialists.
• Evaluated program effectiveness continually through data analysis and outcome measurement metrics.
• Established and maintained relationships with key stakeholders.
• Analyzed data trends to identify potential bottlenecks in operations workflow, implementing strategies to mitigate risks accordingly.

• Led 10 nurses in Pediatric Outpatient Surgery
• Conducted Health history research, medical surgery clearance, and preoperative consultations
• Pediatric sedation and IV infusion therapy nurse
• Cerner Medical Documentation Program trainer
• Magnet Program Unit Chairperson 2010-2012
• ACLS, PALS, PEARS, NPR, and STABLE certified.

• Oversaw the operation of an 18-bed L&D, post-partum and level 2 NICU
• Directed patient care and management of high-risk clients in all stages of the birth process
• Antepartum, Labor and Delivery, Postpartum, and Newborn Nursery RN
• Circulated and assisted in the perinatal operating room
• Resource Nurse for orientation and development of new staff members
• Watchchild Computer Fetal Monitoring Surveillance Trainer 2003-2007
• Policy and Procedure Committee Chairperson 2005-2007
• Performance Improvement Committee Member 2003-2007
• Diabetic Resource Nurse.

• Antenatal Testing/Fetal Monitoring
• Obtained medical and genetic patient histories
• Performed diabetic counseling, teaching, and monitoring for high-risk pregnant diabetic patients
• Supported patient and physician during amniocentesis and chorionic villi sampling.

• Labor and delivery nurse, surgical assistant, and critical care tech.