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Lead Clinical Reviewer Resume

Hartford, CT

PROFESSIONAL SUMMARY:

Responsible and dedicated Licensed Practical Nurse with attention to detail and FIVE years’ experience in nursing. I am seeking an informatics position to consolidate my nursing background and current graduate studies in healthcare informatics.

SKILLS:

  • EHR Super User (EPIC, Centricity, i2iTracks), PACS
  • Lean Management, Technical writing
  • Microsoft Access, Excel, VBA, Word, Outlook
  • Medical Terminology, Utilization Management
  • Intake 98, Queue Manager, Provider Portal
  • Knowledge of HCPCS, CPT, ICD - 10 codes

WORK EXPERIENCE:

Confidential, Hartford, CT

Lead Clinical Reviewer

Responsibilities:

  • Training of new and existing clinical reviewers in all Clinical review processes, developing new training materials.
  • Provide support and feedback to team members with the rest of leadership, coordinators to ensure continuity of UM process. Provide guidance and a reliable resource for other clinical reviewers.
  • Created Desk Level Procedure documents for UM processes.
  • Coordinated 2017 end - of-year enteral project, including analysis of data using Excel, presented findings to UM and provider management teams.
  • Clinical review of prospective, concurrent and retrospective requests within contracted turnaround time TAT.
  • Applying clinical knowledge to determine medical necessity of requested home medical equipment, based on the appropriate healthcare coverage policy, while maintaining excellent quality and productivity.
  • UM elevation of cases - including data collection, analysis, monitoring TAT, tracking cases submitted to internal medical directors and Independent Review Organizations such as MRIoA, AllMed.
  • Communicating effectively with ordering physicians, service providers, and plan members regarding retrieving pertinent clinical information needed for review, approval and denial notifications as required by plan, while maintaining HIPAA laws.
  • Crossed trained in the Sleep Team full process of clinical review of obstructive sleep apnea treatment services; from initial clinical review to UM elevation, denial letter generation and notification.
  • Administration of the denial letter database.

Confidential, New Haven, CT

Responsibilities:

  • Prior Authorization of radiology, home care, Confidential, run weekly reports/tracking. Supervision of other support staff- Medical Assistants, Clinical Health Care workers, LPNs and RNs.
  • Training of staff with equipment use, oriented new licensed and registered nurses to clinic. Routine lab/POCT testing- hCG, Strep, urine dipsticks, glucose, EKG, telephone triage, managing imaging studies U/S, CT scans and referrals.
  • Triage for Urgent Care, routing patients to appropriate clinical service, obtain patient history.
  • Patient teaching: Diabetic teaching, medication reconciliation.
  • Well rounded in emergent care: activation of EMS, setting up IV lines, crash cart use.

Confidential, CT

Charge Nurse

Responsibilities:

  • Floor nurse in charge of medication administration, glucose monitoring, tracheostomy care, gastrostomy tube feeding and care, Confidential catheterization and colostomy care.
  • Document client’s condition in Confidential and nursing needs, implement physician orders, perform and document treatments.
  • Assist with identifying specific patient needs based on patient history and clinical observations.

Confidential, Stratford, CT

Data Entry Specialist

Responsibilities:

  • Updated and maintained data in company database.
  • Manual reviewed data to ensure accuracy, reconcile discrepancies, extract and compile information for reports.
  • Supervised two other data entry personnel, reported to site manager.

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