Amanda Forshee
Studio City
Summary
Dependable Utilization Review Nurse promoting over 12 years of expertise in healthcare industry. Knowledgeable in all case types, with strong work ethic.
Overview
19
19
years of professional experience
Work History
Utlization Review Nurse, Senior Nurse Reviewer
Oscar Health
09.2017 - Current
- Perform prior authorization review services including: Inpatient, Outpatient, OON, Transplants, LLOC, Pharmacy Drug Reviews, Behavioral Health Reviews.
- Complete post claim reviews.
- Maintain continued active licensure's, professional growth, and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice.
- Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
- Follow documentation guidelines for clear and concise decision-making within the utilization review tracking platform.
- Collaborate with clinical leadership to provide onboarding and precepting of newly hired nurses.
- Subject matter expert on Behavioral Health Reviews, Transplants, and OON cases.
- Provide que management, collaborating with MDs, Nurse Managers, Processors and CMs to meet TAT.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Developed documentation templates for the Clinical Review Nurses.
- Participate in executing day to day operations, including providing staffing updates and coverage.
- Participate in hiring process, interviewing potential candidates, collaborating with management, and providing feedback.
- Make consistent referrals to concierge & CCM for care planning, quality for PQIs, and claims for subrogation related cases AND participate in discussion via slack chatroom with CM leads.
- Providing assistance and support to Supervisor with running the OON/High Dollar huddle.
- Developed Behavioral Health Nurse SOP.
Utilization Management Specialist, Leader
Vanderbilt Psychiatric Hospital
09.2015 - Current
- Functioning daily as Child Psychiatry Utilization Management, Daily completion of concurrent reviews, discharges, precertification for Partial Hospitalizations, Residential Treatment Facilities
- Effectively leading treatment team meetings daily, collaborating with psychiatrists, social work, nursing staff, discharge planners, and admissions department
- Daily documentation of completed concurrent reviews, and MD Denials
- Strong knowledge and daily use of AllScripts, HED, and Star Panel documentation databases
- Active member of Nursing Staff Council, providing education regarding nurses role in utilization management to nurses
- Successful in managing time, prioritizing tasks, and competing all within recommended time frame
- Demonstrates knowledge of DSMV terminology, diagnostic clarification, and current guidelines for inpatient criteria/ appeals process for denials
Registered Nurse
Vanderbilt Psychiatric Hospital
07.2012 - 08.2015
- Functioning daily as an integral part of treatment team, representing the nursing staff for the unit
- Effectively communicating with Physicians, Social Workers, Nursing Staff, and family members daily to ensure adequate nursing care and implementing effective treatment plans
- Performing as Charge Nurse 75% of the scheduled time
- Monitoring and assessing patients daily by obtaining vital signs, performing mental health assessments and administering medication
- Participant of Unit Board Meetings
- Implemented and evaluated daily treatment plans for patients by updating goals, assessing outcomes and providing patient education
- Served as communicator for unit between environmental services and admissions to provide effective discharge/admission processes
- Educated patients and families on disease processes, procedures, and medications
- IV/PICC Line Team
Registered Nurse
Harry S Truman Memorial Veterans Hospital
12.2010 - 06.2012
- Performed daily patient assessments by obtaining vital signs, and assessing mental health status
- Accurately documented nursing assessments in CPRS
- Functioned as Charge Nurse 25% of scheduled time
- Worked effectively with interdisciplinary team which included Social Workers, Nursing Staff, Physicians, and Residents
- Led educational based therapy groups with 12 bed unit
- Served as house supervisor for outpatient rehab facility
Nursing Assistant
Harry S Truman Memorial Veterans Hospital
06.2009 - 09.2010
- Obtaining/Monitoring vital signs including daily weights, temperature, respirations, pulse oximetry, blood pressure, and heart rate
- Assisting patients with activities of daily living such as feeding, bathing, and laundry services
- Recording and reporting all information to Charge Nurse, as well as providing documentation in CPRS
- Transportation of patients to additional testing sites such as MRIs, EEGs, and X-rays
- Leading educational based groups
Scheduling Assistant
Hubbell Power Systems
08.2006 - 02.2007
- Oversee and daily management of Kanban System, including creating new Kanban Cards, managing Super Market, or constant checking and upkeep of actual Kanban board
- Daily tracking and expediting of parts on Hot List
- Daily and weekly communication with planners within East Street and Allen Street facilities
- Daily management of Hot List Database and AR Department Tracking Database
- Daily usage of SAP, Microsoft Excel, Access and Microsoft Outlook
Administrative Assistant
University of Missouri Hospital & Clinics
02.2005 - 08.2005
- Daily, weekly, and monthly organization of physicians’ calendar
- Managing and maintaining patient and operative databases
- Scheduling all new patients and returning patients
- Daily organization of incoming faxes and proper mail distribution
- Management of communication system, receiving incoming patient calls & doctors’ offices
- Constant and continuous upkeep of referral and patient film databases
- Creating new patient files, maintaining current and accurate information of patient history
- Compiling all patient files into an accurate and up to date file database
- Daily personal computer usage of IDX, RDP, Microsoft Excel & Microsoft Word
Education
Bachelors of Science -
Central Methodist University
Fayette, MO2010
Skills
- Strong verbal written and communication skills
- Proficient with Microsoft Word, Excel, and ability to learn other software's
- Strong time management, organization, and efficiency skills
- Strong motivation to work independently
Additional Information
- AWARDS , Star Employee- Harry S Truman Memorial Veterans Hospital 2011, 2012 Employee of the Quarter- Vanderbilt Psychiatric Hospital Third Quarter, 2013 Service of Excellence October 2016
Timeline
Utlization Review Nurse, Senior Nurse Reviewer
Oscar Health
09.2017 - Current
Utilization Management Specialist, Leader
Vanderbilt Psychiatric Hospital
09.2015 - Current
Registered Nurse
Vanderbilt Psychiatric Hospital
07.2012 - 08.2015
Registered Nurse
Harry S Truman Memorial Veterans Hospital
12.2010 - 06.2012
Nursing Assistant
Harry S Truman Memorial Veterans Hospital
06.2009 - 09.2010
Scheduling Assistant
Hubbell Power Systems
08.2006 - 02.2007
Administrative Assistant
University of Missouri Hospital & Clinics
02.2005 - 08.2005
Bachelors of Science -
Central Methodist University
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