Zebib Tesfaye
Nolensville
Summary
Proactive Registered Nurse with extensive experience in Utilization Management and Appeals review and proven knowledge of leadership, problem-solving, and prioritization.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Utilization Review - IDR Nurse
Nexus
09.2024 - 01.2025
- Review and assess disputed medical claims for medical necessity and compliance.
- Analyze clinical documentation to support or challenge payment disputes.
- Coordinate the Independent Dispute Resolution (IDR) process, ensuring compliance with federal regulations.
- Manage case workflows from initiation to resolution, meeting strict deadlines.
- Input and maintain accurate case documentation and clinical data in internal systems.
- Act as a liaison between healthcare providers and insurance companies.
- Generate reports on IDR case outcomes.
Prior Authorization - Appeals Review Nurse
Cigna
03.2016 - 05.2021
- Investigated and processed appeals from members and providers for post-service, pre-certification, and/or continued stay of previously denied cases
- Reviewed medical records to assess medical necessity, utilizing clinical criteria (such as InterQual and Milliman), health plan guidelines, medical policies, and/or Medicare guidelines (NCD/LCD)
- Collaborated with providers to gather medical records to evaluate medical necessity and appropriateness of care
- Employed clinical review skills to analyze medical documentation into a clear summary for MD review
- Processed approval and denial letters for members and providers regarding service requests, in line with CMS and NCQA standards
- Provided training, leadership and mentoring for new hire nurses and administrative staff
Prior Authorization Nurse Reviewer
Evicore
03.2015 - 03.2016
- Review clinical information submitted by physician offices/and or imaging centers, to appropriate criteria and standards and authorize services
- If criteria not met, refer to a physician for review
- Know and understand complex case specialties and case reviews
- Maintain current departmental standards related to productivity
- Train in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
Registered Nurse - Cardiac/ICU
St. Thomas West Hospital
02.2013 - 03.2015
- Deliver direct, high-quality care to patients through daily monitoring, documentation, and evaluation of medical conditions
- Assess patient status and promptly inform physicians of any clinical changes
- Conduct thorough assessments and provide care, including the collection and interpretation of various clinical data such as vital signs and lab results
- Care for and maintain life-sustaining devices
- Titrate continuous IV infusions as needed
- Perform dressing changes and assess wounds
- Collaborate effectively with the interdisciplinary team, including therapists, social workers, doctors, and pharmacists
- Prepare patients for surgery and other procedures, ensuring completion of pre-op checklists, medication administration, and coordination of lab and diagnostic tests
- Receive and care for new post-operative patients directly from the operating room
- Manage scheduling for patient admissions and discharges
- Educate patients and families on healthcare needs, conditions, and available options
- Maintain accurate patient charts
- Hold BLS and ACLS certifications
Education
Bachelor of Science - Nursing
Cumberland University
Tennessee01.2012
Bachelor of Pharmaceutical Sciences -
Ohio State University
Ohio01.2007
Skills
- Appeals
- Utilization Review
- Knowledge of CMS rules and regulations
- InterQual
- Milliman (MCG)
- Prior Authorization
- Independent dispute resolution
- Medical Billing
Certification
Active multistate compact nursing license
Timeline
Utilization Review - IDR Nurse
Nexus
09.2024 - 01.2025
Prior Authorization - Appeals Review Nurse
Cigna
03.2016 - 05.2021
Prior Authorization Nurse Reviewer
Evicore
03.2015 - 03.2016
Registered Nurse - Cardiac/ICU
St. Thomas West Hospital
02.2013 - 03.2015
Bachelor of Science - Nursing
Cumberland University
Bachelor of Pharmaceutical Sciences -
Ohio State University
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