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Candidate's Name , RNUtilization Review Care ManagerEMAIL AVAILABLE  PHONE NUMBER AVAILABLE/in/Candidate's Name -Street Address   St. Clairsville, OHSummarySeasoned professional with extensive experience driving positive patient outcomes through comprehensive oversight of the clinical care review process.Demonstrated excellence in developing and administering policies and procedures for utilization control of inpatient and outside referral services countywide; monitoring referral patterns and making recommendations; assisting in development and implementation of procedures to track and trend specialty.Conducted thousands of utilization reviews, demonstrating a strong attention to detail and comprehensive understanding of the review process.Registered Nurse (RN) with a wealth of expertise in utilization review and leadership roles within pediatrics, adult medical/surgical, and the health insurance industry.Proficient in reviewing medical necessity for ongoing client care, ensuring appropriate levels of care are provided and connecting clients to higher levels of care when necessary.Skilled in leveraging technology and leading initiatives to effectively manage and achieve key performance indicators (KPIs).Proven track record of identifying data-driven needs and opportunities for enhancing clinical care review processes on a large scale.Successfully led teams of 10-15 staff members, providing guidance, support, and fostering a collaborative work environment.EducationAssociate Degree in Applied Science in Registered NursingBelmont Technical College, St. Clairsville, OHLicensure/CertificationLicensed RNPrevious Certification in Managed Care Nursing (May 2008)Earlier RolesRegistered Nurse  Ohio Valley Medical Center, Wheeling, WVRegistered Nurse  Wheeling Hospital, Wheeling, WVAreas of ExpertiseUtilization Review & ManagementClinical Care ManagementPatient Advocacy & CounsellingLeadership & Team ManagementAdmission AuthorizationDischarge PlanningCare TransfersProcess ImprovementProfessional ExperienceCotviti South Jordan, Utah 07/2023-present Auditor, Clinical ValidationAudited medical records for short stay inpatient admission payment accuracyHighmark, Inc. Pittsburgh, PA 10/2018  4/2023Manager, Integrated CareTasked with overseeing a department that experienced an influx of team members from various parts of the organization due to manager attrition, successfully combining all areas into a unified team with diverse skill sets.Recognized as the manager of the team with the highest employee satisfaction, as indicated by the core behaviors survey.Managed 13-20 nurse care managers to meet daily compliance for medical and commercial inpatient review completion.Effectively manage a team of 10-15 employees, ensuring the seamless delivery of care to hundreds of patients on a daily basis.Played a vital role as a member of numerous project teams, contributing to complex care rounds, compliance initiatives, and the implementation of Agile methodology.United Healthcare Pittsburgh, PA 1/2016  10/2018Inpatient Care ManagerActed as the primary contact for assigned hospitals, handling all aspects of utilization review efficiently and effectively. Managed the care of 20-25 patients on a daily basis, ensuring their needs were met and coordinating with providers.Conducted 15-20 inpatient case reviews daily, meticulously evaluating each case to ensure appropriate care and utilization of resources.Developed strong relationships with healthcare providers, fostering effective communication and collaboration to deliver optimal patient care.Acuity Specialty Hospital Steubenville, OH 2/2015  1/2016Clinical LiaisonTook on the responsibility of advocating for patients during the pre-admission process, collaborating with clinical teams and groups to assess the medical needs and conditions of both current and prospective patients. Worked collaboratively with various departments and facilities, fostering seamless coordination and communication to facilitate optimal patient care.As a patient and provider-facing liaison, effectively coordinated the review of medical records and facilitated the admission process to Long Term Acute Care, ensuring appropriate and timely care for 1-5 patients on a daily basis.Fostered strong relationships throughout the facility, serving as a valuable hospital resource and establishing a reputation for achieving impactful results.The Health Plan of the Upper Ohio Valley St. Clairsville, OH Till 2/2015Utilization Review NurseHand-selected as the lead Utilization Review Nurse to provide support and guidance to the nurse review team members. Conducted 25-30 daily admission, concurrent, and retrospective clinical reviews, utilizing InterQual criteria to assess the severity of illness and intensity of service. Supervised a team of 10 in-house and on-site employees, overseeing their performance and ensuring adherence to quality standards.Recognized for successful implementation of discharge planning strategies and ensuring appropriate level of care transfers.Completed 25-30 inpatient case reviews on a daily basis, demonstrating strong clinical expertise.Assumed supervisor duties for a team of 10 nurse reviewers both in the office and on-site, effectively managing their workload and providing leadership and guidance.Wheeling Hospital Wheeling, VARegistered NurseDelivered exceptional care to patients across all assigned units, collaborating seamlessly with the care team to ensure comprehensive patient support. Maintained a strong focus on patient well-being and safety, consistently providing attentive and compassionate care throughout the treatment process.Received commendation for demonstrating excellent observation skills, displaying sound clinical judgment, and exhibiting exceptional oral and written communication abilities.Effectively communicated critical patient information to the care team, fostering a collaborative and informed approach to patient care.Prioritized clear communication with patients and their families, ensuring they were well-informed and involved in the care decisions.