• Evaluating a member’s clinical condition through the review of medical records to determine the medical necessity for outpatient services. Applying medical knowledge to medical necessity reviews. Provide a front-line regulatory/compliance function in evaluation and application of the criteria.• Authorizing services determined to be medically necessary based on the independent review. Use of policies and experience with InterQual criteria.• Refer or consult with the medical director for cases that do not meet criteria. Work with providers as needed to obtain additional clinical information.• Compiling information, data entry and other tasks to build cases. Complete and communicate denials and approvals to providers. Meet productivity expectations.

• Evaluating a member’s clinical condition through the review of medical records to determine the medical necessity for outpatient services. Applying medical knowledge to medical necessity reviews. Provide a front-line regulatory/compliance function in evaluation and application of the criteria.• Authorizing services determined to be medically necessary based on the independent review. Use of policies and experience with InterQual criteria.• Refer or consult with the medical director for cases that do not meet criteria. Work with providers as needed to obtain additional clinical information.• Compiling information, data entry and other tasks to build cases. Complete and communicate denials and approvals to providers. Meet productivity expectations.• Assist to launch the new UM department in NC and trained new nurses to the department as it grew.

• Assess members with physical, behavioral, developmental, and mental illness. Plan, coordinate, implement and evaluate care for members with chronic and complex health care needs. • Coordinate care needs across various service delivery systems and community support. Monitor the individual for social service and custodial needs within the community. Offer long-term services and support to help the individual live within the community in the safest and least restrictive way. Identify resources and provide them to members. Help to create back up plans.• Facilitate transition to alternate care settings such as hospital or nursing home. • Educate members on illness, medications, health care needs and benefits. Assist members to create goals in their plan of care. Help members achieve goals, and help members overcome obstacles to achieve their goals.

• Working with a multidisciplinary team to coordinate and provide the best care possible for the patient to improve the patient’s status while assessing and educating the patient/family.• Complete an initial and ongoing assessment of patient and family to determine home care needs, complete physical assessment and history, and initiate the plan of care and make necessary revisions as patient status changes. Maintained a case load of patients. • Multidisciplinary meetings to establish goals and incorporate therapeutic, preventive, and rehabilitative nursing actions with the Core and Expanded Teams to discuss care plan and work towards discharge. Proficient with the Oasis program.• Other job duties include set up patient with the telehealth system and CHF disease management, drawing blood for lab work, chemo disconnect, wound vacs and pleurx drain, PICC/Port maintenance, monitoring vital signs, medication management, educate patients on self-management, prevention, safety, pain management, disease process and management, Iv antibiotic and fluid hydration infusions, as well as diet teaching. • Trained with the Orthopedic department to help provide smooth discharge planning and transitions back to the home

• Working with a multidisciplinary team to coordinate and provide the best care possible for the patient to improve the patient’s status while assessing and educating the patient/family.• Complete an initial and ongoing assessment of patient and family to determine home care needs, complete physical assessment and history, and initiate the plan of care and make necessary revisions as patient status changes. Maintained a case load of patients.• Multidisciplinary meetings to establish goals and incorporate therapeutic, preventive, and rehabilitative nursing actions with the Core and Expanded Teams to discuss care plan and work towards discharge. Proficient with the Oasis program.• Other job duties include set up patient with the telehealth system and CHF disease management, drawing blood for lab work, chemo disconnect, wound vacs and pleurx drain, PICC/Port maintenance, monitoring vital signs, medication management, educate patients on self-management, prevention, safety, pain management, disease process and management, Iv antibiotic and fluid hydration infusions, as well as diet teaching.• Trained new nurses to the department.

• Assess care plan and evaluate patient needs, while carrying out MD orders. • Administered medication, gathered vital signs, provided wound care and changed wound vacs. Monitor and read telemetry strips and address urgent results. Provided respiratory and ventilator monitoring, start IV lines, Iv infusions of fluids and medication. • Provided respiratory and ventilator monitoring. Coordinated discharge planning, charge nurse duties, educate and communicate with patient and families to ensure the most optimal recovery. • Rapid Response team member, CPR certified. ACLS certified.

• Focused nursing care on musculoskeletal trauma injuries and routine orthopedic procedures.• Administered ordered treatments such as leach therapy to promote circulation, wound vac, grafts, and care for amputation site, pain management by maintaining epidural lines, teaching PCA use, breakthrough pain management, infection control practices, assess for DVT/PE, compartment syndrome, volume issues, depression and anxiety. • Worked closely with the OT/PT team and discussed rounds with the multidisciplinary team.