Experienced RN, BSN, CCM skilled in utilization review of patient hospital admission status. Focusing specifically on utilization review of surgical cases, imaging, and all other inpatient and outpatient hospital procedures. Reviewing to ensure proper patient treatment and verify healthcare costs and authorization/guidelines are followed for appropriate reimbursement.  Working within CMS MEDICARE guidelines and policies. Adept in meeting Medicare documentation criteria for LCDs and NCDs. Demonstrated history with Providence of creating strong clinical documentation in a smart phrase to ease the way of physicians. Receiving a 100% audit passing rate from Medicare for this clinical statement. This smartphrase is now used across other Providence ministries.Knowledge of or how to locate the fee schedule, medical clinical policies for DSHS Medicaid, managed Medicaid and commercial plans for coverage criteria. Optimal in obtaining and presenting crucial information and my anticipated outcome for reimbursement to leadership reviewing high dollar surgical procedures, imaging, new or costly IV drugs. Referring cases to UM MD as needed. Providing clear communication with physicians clinics requesting and advising if they may or may not schedule based on review of their prior authorizations or payer source in place.. Excellent communication skills, creating relationships with the consistent daily contact between myself, the physician clinics, insurance companies, Providence financial counseling and physicians. This ensures the best outcome for the patient, clinic and facility. Strong skills in the ability to educate. Providing information to Providence clinics, as well as outside clinics in order to maintain excellent working relationships where questions are always welcomed.