• Outpatient, Inpatient, and Medicaid Review• Review given cases for medical necessity• Verbal review to Medical Directors for consideration of cases not meeting MCG criteria• Follow hospital course for medical necessity, continuity of care, and discharge planning• Application of MCG criteria, NCQA requirements, and TAT time requirements• Utilization of Concord system for facility communications

• Experienced in both Utilization Reviews and Case Management (high risk maternity, neonatal, pediatrics, orthopedics, neurology, injections, infusions, medicine, surgery, skilled nursing facility, long term care, rehabilitation, cardiology, hospice, cancer, inpatient stays, home health care, scans and procedures)• Create a patient-centric case management plan that is implemented, coordinated, monitored and evaluated on an ongoing basis• Work with Specialty Pharmacies, large case reports, stop loss and high dollar drug reports• Delivery of care through telephone-based system assessment, per protocol and experience• Proficient on company's private electronic medical records and financial medical systems (FMS)• Liaison between patients, families, physicians and other providers to guarantee high quality care with a balance between business needs and patient advocacy, through skilled communication and building collaborative relationships• Sensitivity to cultural differences• Work-from-home since March 2020• Managed immunization clinics with safe delivery of vaccines• Personal skills: time management, problem resolution, effective decision making, knowledge of managed care strategies, effective written and verbal communication, ability to coach and educate staff and patients/families, ability to adapt to unpredictable situations and manage multiple projects

• Nurse Supervisor for Prior Lake, Eden Prairie, and Savage clinics• Managed Coumadin dosing clinic• TB draws