Reviewed clinical information for national care guideline criteria and appropriateness of care for out of state Medicare/Commercial plans. Was promoted from Care advocate with Optum to UHC Supervisor in the Appeals Department. Helped Identify FTE cost saving processes including elimination of unnecessary case nonperformance group assignments. Promoted the use of efficient overtime usage based on the seasonal workflow. Also directed cases to the most qualified internal physician specialty to avoid external contract expenses. Supervised and coached a team of 16 Appeals nurses, gave honest feedback during employee reviews, doing root cause analysis with unusual cases. Assisted the legal team on Gender dysphoria cases and State mandate cases in providing feedback to state departments of insurance and stakeholders. Utilized broad experience background to identify patients in critical need and medical necessity.

Reviewed clinical information for national care guideline criteria and appropriateness of care for the TX Medicaid/Medicare plan. Provided specific insight for appropriateness of various levels of care changing the current trend. Provided procedural recommendations expediting identification and denial of non-appropriate claims.

Reviewed clinical information for MCG criteria and appropriateness of care for the Behavioral Health Medicaid plan. Helped set standards of quality for pediatric and adult outpatient care management. Improved accuracy of entire authorization shells of behavioral health and long-term services and supports. Created an administrative denial letter template and process with the chief medical director to avoid the liability of duplicate claims reimbursement.

Screened patients for present-on-admission conditions and prioritized higher level of care patients making admission recommendations to physicians for a wide variety of patients. Reviewed clinical information for medical necessity, transition navigated patients at discharge, and proactively communicated with physicians to drive critical level-of-care decisions.

Directed and supervised staff in performance of duties. Oversaw implementation and evaluation of home health client care services as well as all Continuous Quality Improvement (CQI) and (OASIS) Outcome and Assessment Information Set utilization review activities.

Reviewed denied cases for precertification, authorization, and medical necessity claim denial codes on insurance claims. Coordinated billing and coding to enhance timely filing of medical necessity appeals with correct billing codes. Led business office, case management, and admissions coordinating efforts to reduce billed/paid reimbursement gap. Intervened on denied cases for appropriate level of care; appealed denied cases. Recovered $1Million+ through aggressive appeals on denied cases. Performed chart reviews utilizing MCG and InterQual criteria while leveraging advanced clinical judgment. Leveraged peer-reviewed articles, regulations, CDC fact sheets, and corrected MCG and InterQual criteria to optimize insurance appeal outcomes for diverse patient populations. Created methodology for analyzing appealed cases for effectiveness, trends, and causation of denials.

Set exceptional standards for clinical information review using MCG care guidelines and professional judgment to help design and launch new Utilization Review department; supervised team of 6. Partnered with Mental Health, LTAC, Rehab, and SNF facility care transition navigators reducing inpatient hospital days. Identified cost-effective alternative treatment options to improve patient outcomes. Thoroughly researched cost-effective services within the scope of benefits; coordinated resources to implement appropriate treatment options. Reviewed denied cases leveraging an effective denial coaching strategy for peer-to-peer step, downgraded lower- level appropriate cases, and appealed Inpatient appropriate cases.

Collaborated with medical directors, providers, patients, insurance representatives, and appeals department to facilitate insurance authorization and ensure appropriate coverage for services for multi-million-dollar portfolio of managed care cases. Made coverage request decisions based on care guidelines, organizational best practices, and other relevant data. Trained and mentored staff to align admission data with medical necessity clinical documentation in compliance with federal and state regulations. Worked self-directed and within a team environment to provide case documentation for clinical pertinence reviews on patient admissions, continued stays, denial reconsideration, and appeals for patients of all age groups. Slashed occurrence of insurance denials by encouraging registration and insurance departments to obtain insurance ID cards, notify insurance company for Inpatient requests, and verify coverage within 24-hours of admission.

Reviewed clinical information for medical necessity, transition navigated out-of-network patients to in-network facilities, and proactively communicated with appropriate stakeholders to drive critical level-of-care decisions. Researched cost-effective services within scope of benefits and coordinated resources to implement appropriate treatment options for insurance plan. Carried out utilization management and care coordination activities.

Screened Emergency Department patients for present-on-admission conditions and prioritized higher level of care patients. Coordinated with physicians, case managers, and nurses to accurately document severity of illness and medical necessity for broad variety of physical, neurological, and mental illnesses and conditions. Provided leadership as charge nurse and improved patient outcomes through patient and family education. Carried out all nursing duties per compliance regulations and policies. Maintained current Trauma nurse and Advanced Life Support certifications while caring for gunshot wound victims and multiple trauma patients. Maintained a safe care environment for everyone with a focus on privacy, dignity, and respect.

Worked in various capacities for diverse companies and agencies nationwide.