Summary
Detail-oriented Utilization Review RN with 5 years of experience in case management and utilization management. Skilled in analyzing clinical service requests, coordinating care, and ensuring regulatory compliance. Proven ability to improve care coordination and support interdisciplinary teams.
Experience
- Reviewed 60+ clinical service requests weekly, ensuring 98% compliance with evidence-based guidelines.
- Accessed and managed payer portals to secure authorization numbers, reducing claim denials by 20%.
- Analyzed utilization data and identified trends, leading to a 10% improvement in care coordination.
- Acted as a resource for complex case issues, supporting a team of 12 nurses.
- Coordinated care for a panel of 120 patients, reducing hospital readmissions by 15% in one year.
- Assessed and managed member panels via telephonic outreach, improving patient engagement rates by 18%.
- Assisted with departmental projects, contributing to a 25% increase in process efficiency.
Education
Courses
- Registered Nurse (RN) License, Texas Board of Nursing
- Certified Case Manager (CCM), Commission for Case Manager Certification