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Click here or scroll down to respond to this candidateCandidate's Name
Henderson, NV Street Address PHONE NUMBER AVAILABLE EMAIL AVAILABLESummarySkilled Utilization Review Nurse, behavioral health and medical services, inpatient and outpatient review experience. Seeking position in utilization management, case management of adult, senior and child/adolescent cases.SkillsUtilization Management RNexperienced with reviewing for medicalnecessity for behavioral healthservices: inpatient, outpatient,intensive outpatient, partialhospitalization, and residential care.Review experience for Medicaid andMedicare MCO insurance companies aswell as commercial plans product line.Concurrent and pre-admission reviewfor medical and behavioral healthservices.Clinical rounds and letter writing fordenied services.Referred for review with medicaldirectors did when the case did notmeet all parameters of medicalnecessity per the Interqual or MCGguidelines.ExperienceUtilization Review Nurse Nov 2021 to Jun 2023Prominence Health Plan Reno, NVDetermined medical necessity and cost-effectiveness of services through utilization review processes.Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries. Referred cases to secondary review for failure to meet MCG criteria. Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.Utilization Management Nurse May 2019 to Jul 2021ERP International LLC Las Vegas, NVCollaborated with medical management/ physicians, case managers, discharge planner, social worker group meetings to identify issues and find cost-effective solutions.Kept detailed documentation on all utilization reviews by using Interqual medical necessity tool and Genesis/ Cerner software.Reviewed patient admissions to determine medical necessity as directed by Interqual and clinical criteria.Determined medical necessity and cost-effectiveness of services through utilization review processes.Contacted insurance carriers to obtain authorizations for services delivered to patients.Collaborated with interdisciplinary team of professionals as well as patients and families to determine appropriate treatment optionsin supporting discharge planning. Gathered community resources and coordinated referrals to obtain services. Utilization Management Nurse Oct 2018 to Apr 2019Total Med Staffing, Silver Summit Las Vegas, NVCollaborated with case managers and medical directorin group meetings to identify issues and find cost-effective solutions.Kept detailed documentation on all utilization reviews by using Interqul software and Centene software.Referred cases to secondary review for failure to meet Inpatient Acute criteria. Reviewed patient admissions to determine medical necessity as directed by Interqual and clinical criteria.Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries. Managed letters, reconsideration and first level appeal processes pertaining to denials and potential denials as outlined by insurance carriers. Utilization Management Nurse Mar 2016 to Aug 2018Anthem Blue Cross Blue Shield Las Vegas, NVCollaborated with Medical Director, community mental health providers, and case managers in group meetings to identify issues and find cost-effective solutions. Kept detailed documentation on all utilization reviews by using . Referred cases to secondary review for failure to meet Milliman and Robertson criteria.Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations, as well as clinical case presentations . Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries. Monitored and recorded patient condition, their psychiatic conditions, recovery progress and medication side effects.Care Manager Jun 2014 to Nov 2015Value Options/Beacon Health Care Options Las Vegas, NV Advocated for members and families, with mental health and medical diagnosis, to coordinate care and navigate resources within Medicaid system. Determined functional status, activity, acuity and self-management levels to make proper care referrals.Cooperated with local service providers, outreach workers, case managers and collaborative agencies to facilitate services for members. Protected patient data in alignment with HIPAA privacy protocols. Constructed case notes and comprehensive reports, including data entry into McKesson portal.Participated in case conferences with multi-disciplinary team to discuss client care planning and progression.Care Manager May 2014 to Nov 2015Beacon Health Options (Value Options) Las Vegas, NV Collaborated with various healthcare providers to facilitate delivery of services. Lowered costs while improving care quality by coordinating services and collaborating with dedicated healthcare team.Optimized program resource utilization to prevent unnecessary hospital admissions. Coordinated support services and optimized communication between healthcare workers and patients.Developed appropriate care plans for at-risk individuals and high-risk families. I worked on a program called Health Care Guidance Program, enrolling patients, and supporting them on phone and in person to get medical and mental health needs met. Visited a few of our patients when they were hospitalized on Boulder City Hospital Psychiatric Unit.School Nurse Aug 2004 to Aug 2014Clark County School District, CCSD Las Vegas, NV Evaluated students with health concerns or injuries to develop plan of care or provide reference to appropriate healthcare providers.Coordinated with families, school personnel and healthcare professionals on behalf of students to advocate for healthcare needs and provide medical information to medical specialties; and presented assessments in IEP . Assisted in development of school safety plans that targeted problem areas such as medical emergencies and suicide risk.Answered patient calls, identified issues and determined how best to provide assistance within parameters established by facility and supervisor. Monitored infection control procedures to verify facility-wide health and safety. Rapid Response Nurse May 2011 to Oct 2011HBI- Human Behavior Institute Las Vegas, NVPerformed mobile and telephone mental health assessments for adult, geriatric, and adolescent clients with psychiatrist and insurance precertification for inpatient admissions.Mobile Assessor Intake Jul 2007 to May 2011Spring Mountain Treatment Center Las Vegas, NVProvided client assessments upon admission and discharge. Please see above descriptions Montevista.Mobile Assessor Jan 2004 to Jun 2007Montevista Hospital Intake Las Vegas, NVServed as clinician for patients with bipolar, depression, anxiety and personality disorders.Monitored patients prescribed psychotropic medications to assess medications' effectiveness and side effects.Facilitated patient flow during emergency Legal 2000-involuntary commitment situations, performing evaluations, assigning DSM IV, contacting admitting psychiatrist on call, and contacting insurance pre-authorization for admissions and transfers. RN Staff Nurse Jan 2002 to Jun 2004Havenwyck Hospital Auburn Hills, MIManaged 20 patients and care plans in child and adolescent mental health facility in Auburn Hills, MI.Documented all medications administered to mental health patients, following instructions from physicians and healthcare providers. Provided client assessments upon admission and discharge. Cultivated relationships with patients, discussing ways to help improve overall health while alleviating self-harm practices.Communicated with patients regarding continuing care and medications and discussed treatment plans with family members and guardians. RN Instructor May 2003 to Aug 2003Schoolcraft College Livonia, MIMaintained current, accurate records of course enrollment, attendance and student academic progress.Contributed subject matter expertise toward improving overall training program and skills displayed by student nurses.Evaluated students to identify knowledge gaps and conduct thorough assessments. I was covering for a faculty for summer. I did psych-mental health nursing lecture and clinical instruction.Contract RN Faculty Jun 2002 to Aug 2003Monroe County Community College Monroe, MIRelayed feedback on clinical settings' effectiveness in enabling students reach course and program goals.Taught students how to intervene in medical emergencies and how to perform head to toe assessments.Delegated patient assignments to students based on individual learning needs and patient assessments.Contract Faculty Aug 2001 to Apr 2002Baker College Warren, MIObserved and evaluated student performance in meeting course objectives and student learning outcomes through assignments, projects and examinations. Participated in planning, implementing and evaluating assigned courses for continued development of nursing curriculum.Evaluated students to identify knowledge gaps and conduct thorough assessments. Psychiatric Nurse Case Manager Apr 1999 to Oct 2001 Southwest Mental Health Detroit, MICommunicated with patients regarding continuing care and medications and discussed treatment plans with family members and guardians. Met patient needs by devising and coordinating highly tailored care plans for each individual. These were child adolescent patients with mental health needs in ACT program, Assertive Community Treatment.Recorded comprehensive patient histories and coordinated treatment plans with multi-disciplinary team members.Consulted with psychiatrists about client medication changes, issues with medicine compliance and efficacy of medications.Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.RN Educator Jan 1999 to Aug 2001HAP Health Alliance Plan Detroit, MIEnhanced training delivery by incorporating new technologies and techniques alongside proven methods.Delivered industry-leading educational experiences by integrating theoretical knowledge, evidence-based principles and expertise in clinical nursing. Set up community service announcements, presented classes at senior centers and recreation centers on Living a Healthy Life with Chronic Conditions (Stanford Program).RN Supervisor Apr 1992 to Jul 1996Aurora Child and Adolescent Detroit, MICommunicated with patients regarding continuing care and medications and discussed treatment plans with family members and guardians. Managed 45 patients and care plans in child and adolescent mental health facility in Detroit, MI.Documented all medications administered to mental health patients, following instructions from physicians and healthcare providers. Also did transfer to subsidiary Michigan Health Care and worked on program called Mobile Assess and OBRA to assess mental health needs for seniors. RN Staff Nurse Mar 1994 to May 1995Fairlawn Hospital-State of Michigan Pontiac, MIEffectively managed daily charting for each patient. Managed 20 patients and care plans in adolescent mental health facility in Pontiac, MI.Documented all medications administered to mental health patients, following instructions from physicians and healthcare providers. Cultivated relationships with patients, discussing ways to help improve overall health while alleviating self-harm practices.Contractor RN Jul 1991 to Oct 1993Monroe County Mental Health Monroe, MIObtained recommendations for inpatient or outpatient level of care by discussing cases with physician advisor.Helped patients navigate DD Developmental Disability program with OBRA with deinstitutionalization and returning back to their communities and day treatment. Nursing assessment of medical needs on severe to profound developmentally delayed persons, participated in the multidisciplinary treatment teams. Registered Nurse, Inpatient Psychiatric Unit Aug 1985 to Oct 1989 Oakwood Heritage Hospital Taylor, MISupervised ancillary staff of 30 nurses and mental health workers, including scheduling shifts, delegating assignments and monitoring quality of care. Monitored infection control and critical incidents and made changes and improvements to processes where necessary.Partnered with organizational and unit leaders to devise QA/QI initiatives, continuously improving delivery of care, patient outcomes and overall services. Advised, coached and mentored experienced and student nurses on medical issues, crisis management and appropriate nursing interventions. Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.Supervised nurse administration of oral, intramuscular and IV medications to patients as prescribed, monitoring responses for adverse reactions. Education and TrainingMaster of Science, Psychiatric Mental Health Nursing May 1999 University Of Michigan - Ann Arbor Ann Arbor, MI Bachelor of Science, Nursing Jun 1978Wayne State University Detroit, MI |
