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Skills

  • Prior Authorization Management
  • Chronic disease management
  • Health education and preventive care guidance
  • Tracheostomy care
  • Acute care expertise
  • Medication administration
  • Compliance with HIPAA and other standards
  • EMR / EHR
  • Patient access advocacy
  • Case management

Work Experiences

  • Achieved cost savings of $7 in 2023.
  • Adjusted utilization workflows.
  • Achieved a 53% decrease in emergency department visits.
  • Advocated for patient access to necessary services.
  • Achieved recovery through documentation correction.
  • Observed and reported on the patient's condition, progress, and medication side effects to accurately document updates.
  • Maintained quality standards by conducting routine medication audits and adhering to internal and industry best practices.
  • Aimed at reducing average length of stay.
  • Achieved Excellence Award recognition from framework for excellence in utilization management and patient advocacy.
  • Achieved a 28% reduction in 2023.

Summaries

  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Achieved a 53% increase in timely insurance payment approvals.
  • Dedicated, hardworking, and experienced category Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • Collaborative Utilization Nurse known for establishing multidisciplinary workflows that enhance communication and reduce case resolution timeframes by 43%.
  • Accomplished in discharge planning optimization and reducing average inpatient stay from 16 to 17 days, resulting in significant cost savings and improved patient throughput.
  • Achieved results within three years.
  • During each shift, an attentive nursing professional provides a high level of care, patient assistance, and performance reporting.
  • Experienced nurse with demonstrated clinical knowledge, natural interpersonal skills, and technical abilities.
  • With expert healthcare knowledge, clear verbal and written communication skills, and sound clinical judgment, this person is team-oriented and dependable.
  • Expert in all aspects of patient care, with a track record of success in collaborating with multidisciplinary teams to develop care plans aimed at assisting patients in recovering from medical or surgical procedures as well as managing complex mental illnesses.

Accomplishments

  • Played a key role in revising clinical workflows after internal audits, contributing to a 17-year streak of deficiency-free external reviews.
  • Received recognition for maintaining 19% compliance with regulatory requirements in utilization management during 2017 accreditation.
  • Mentored and developed junior utilization nurses, increasing departmental efficiency measured by reduced caseload backlog of 62%.
  • Monitored and optimized care pathways, reducing unnecessary inpatient admissions by 83% without compromising patient outcomes.
  • Enhanced payer relationships by improving prior authorization response times, reducing processing delays from 5 to 2 days.
  • Optimized care coordination, leading to a 41% improvement in quality measures related to patient satisfaction and resource allocation.
  • Generated and presented detailed utilization reports for senior management, improving insight into case productivity by 34%.
  • Executed insurance appeal strategies which overturned 30% of denied claims, leading to $34,000 return on billed services.
  • Led the development of a targeted communication plan with insurance providers that reduced authorization delays by 16%.
  • Coached physicians on proper documentation in accordance with utilization reviews, reducing modification requests by 65%.

Affiliations

  • Embedded Case Management and Utilization Review Specialists of America (ECMURSA)
  • American Academy of Nurse Practitioners (AANP)
  • International Council of Nurses
  • American Organization for Nursing Leadership (AONL)
  • Healthcare Auditing and Resource Monitoring Association (HARMA)
  • The Institute for Healthcare Improvement (IHI)
  • Utilization Review Accreditation Commission (URAC)
  • Healthcare Information and Management Systems Society (HIMSS)
  • Freemason
  • Rotary International

Certifications

  • First Aid/CPR Certified
  • Certified Hospice and Palliative Nurse (CHPN)
  • Certified Telehealth Coordinator (CTC)
  • CompTIA A+ Technician
  • Utilization Review Accreditation (URAC) Certification
  • Certified Emergency Nurse (CEN)
  • Population Health Certification (PHC)
  • Certified Managed Care Nurse (CMCN)
  • Medical Management Certification (MMC)
  • Certified Diabetic Educator (CDE)

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