Wendy B. Leslie

In the 14 years at GEHA I have been responsible for performing prior authorization, prospective, concurrent and retrospective reviews on inpatient admissions, outpatient procedures, services and supplies utilizing national medical guidelines such as Interqual and Milliman criteria to determine medical necessity. Discharge care coordination with hospital discharge planners to transition through the continuum of care. Post hospital phone calls made to patients to ensure self-management after discharge. Review of provider disputes and appeals. I assess patient charts and treatment history to determine medical necessity. Collaborate with medical director for medical necessity reviews that do not meet national medical guidelines. Prior authorization of DME and pain management procedures, spinal surgery and coordination of plan benefits for members and providers. Assisting patients in the navigation of the healthcare system and maximizing their healthcare benefits.

In my current role as a 2nd level Appeals Nurse I review medical records, all previous denials and appeals. I utilize national medical guidelines to include Interqual, Milliman and posted policies. I am familiar with ICD-10, CPT, and HCPCS codes to support appeals. I pay close attention to detail and utilize my critical thinking skills to evaluate complex cases and make evidence-based decisions. I am able to handle multiple appeals efficiently under tight deadlines. Using root cause analysis I Investigate denials and identify patterns to prevent future issues.

I am proficient in Word, Excel

• Responsible for providing skilled nursing care to terminally ill patients. I was responsible for developing and implementing care plans based on the patient’s individual needs. Administered medications, wound care and other treatments as prescribed. Evaluated and documented the patient’s response to treatments and interventions. I educated patients and their families on palliative care and end-of-life issues, medication administration and symptom control. Supported, provided emotional support and counseled patients and their families through the dying process. Collaborated with other healthcare professionals and the interdisciplinary team to ensure continuity of care. I managed complex caseloads effectively, prioritizing tasks based on patient acuity levels.

• I was responsible for providing skilled nursing care to terminally ill patients. I was responsible for developing and implementing care plans based on the patient’s individual needs. Administered medications, wound care and other treatments as prescribed. Evaluated and documented the patient’s response to treatments and interventions. I educated patient and their families on palliative care and end-of-life issues. Supported and counselled patients and their families through the dying process. I collaborated with other healthcare professionals and the interdisciplinary team to ensure continuity of care.

• Onsite Concurrent Review RN – Responsible for Concurrent Utilization Review onsite in assigned hospitals utilizing Milliman and Interqual Criteria. Discharge planning and Case management. Assisting with LTAC, SNF, home health, DME and infusion resources and providing prior authorizations. Extensive computer usage.

Performed concurrent reviews, including determining member's overall health, admission details and reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to National Guidelines such as Interqual and Milliman guidelines. Collaborated with hospital case managers to assist with the discharge plan keeping in mind the patient's medical benefits to ensure cost effectiveness. Daily review of care and plan of care with medical directors to ensure prompt decisions of medical necessity and insurance payor decisions. Skilled at tailoring messages to diverse audiences as I communicated with a different groups of patients, their families, hospital staff and other care providers outside of hospital.