Judith Engle Email & Phone Number

Cincinnati, Ohio, United States

Cncinnati , Ohio

High performing case management/ utilization review RN with 30 +years of experience. My clinical knowledge and expertise spans all levels of utilization, case management and quality review. Expansive experience working in all levels of healthcare to include acute hospital, LTACH’s and home care. In addition have years of experience working in the commercial insurance industry. Recent experience involves working as an appeals coordinator with high rate of successfully overturned denials both from Commercial insurance plans, Medicaid and Medicare. Advanced knowledge of Interqual, MCG criteria, Medical policies for commercial plans and NCD’s, LCD’s, coding and MUE edits for Medicare denials. Resourceful professional seeking all available resources inside and outside the UC Medical Center to prove medical necessity for all UC Medical center facilities across the spectrum (Acute Inpatient, Outpatient, LTACH and Skilled care). Consummate health care professional in this ever-changing complex health care delivery system proactively meeting the challenges, meeting compliancy standards, removing barriers and managing successful outcomes for patients and families.

2129 Auburn Avenue, Cincinnati , Ohio 45219

Coordinated care with the interdisciplinary team of a high level surgical unit. Promoted to position of ICU case manager: Medical, Surgical and Cardiovascular units.Chosen to assist orientation of new employees about case managementAssisted team with the utilization review processes: educating team on obtaining authorizations andprocesses and guidelines for all insurance companies.Member of the Surgical Process Improvement committee

2129 Auburn Avenue, Cincinnati, "

Management of LTAC hospital referrals with goal of admission to hospital. Assessment of patients clinical status and medical needs assuring Medicare guidelines are met.Responsible for the education and marketing of hospital staff, physicians, providers, patients on LTAC criteria and hospital services and resources.Complete all pre-certification requirements as outlined per third party payors.Highly developed communication skills required to keep hospital staff team and referral sources abreast of all developments on case for smooth transition from acute care setting toLTAC.

Act as key member of the multidisciplinary team in the identification of patients with complex care needs.Utilize strong assessment skills to determine appropriate level of care for patients. Initiate direct referrals for home care, hospice, skilled facility and LTACH's.Effectively communicate discharge plan and benefits to patient, families, physician and referral sources .Act as patient and family advocate in coordination of hospital services and discharge plan. Maintain accurate documentation trail to provide health care team all pertinent information. Participated in daily patient rounds to assure compliance with regulatory bodies, quality measures and identifying high risk patients.Assisted in development of discharge planning assessment tool and trained staff. Assisted in implementation of high risk readmission assessment tool.Assisted with implementation of programs to improve quality management (MI, asthma, COPD, Pneumonia and CVA).

Implemented the telephonic catastrophic care management programAttended care conferences, made discharge phone calls, and kept a ongoing client files/phone logs for patients followed in care management Certified all medical services- outpatient, inpatient, skilled and LTACH's.Completed quarterly reports to employer groups on all clients maintaining client confidentiality. Act as interface liaison with Third party administrators, reinsurance companies and ancillary providers for trouble shooting, conflict resolution and client relations.Coordinated account implementation and planning meetings to operationalize new customers and maintaining existing customers.Assisted in policy and procedure development in preparation for URAQ accreditation. (Successfully achieved 2004).

On-site Reviewer at many of the greater Cincinnati area hospitals Member Appeals committeeDeveloped and implemented Transplant program

Coordinated the daily operations of the Managed Care HMO product.Oversight of concurrent field nurses and the functions of pre-certification, benefit administration and referral management.

Coordinated the Utilization Review and Quality Improvement Activities for all patients . Weekly Case presentation to Medical Director.Met length of stay objectives for 1991- 1992.

Developed and managed the Utilization Review Department. Implemented review process and trained staff on Interqual criteria.Active member of the Utilization Review Department comprised of physicians, finance department and social services staff.

In-home RN providing skilled care to a caseload of patients . Promoted to Supervisor of field nurses .Hired and supervised field nurses in Medicare skilled home care.Reviewed and completed all necessary documentation for Medicare reimbursement.

Bachelor Of Science, Nursing (Bsn)

Diploma Degree, Registered Nursing/Registered Nurse