Deborah Hoffman
Calimesa
Summary
Skilled Utilization Review Nurse offering talents in prior authorizations and denials. Pleasant individual with over 30 years in the nursing field. Ready to join new company that appreciates attention to detail and exemplary clinical review skills.
Overview
31
31
years of professional experience
Work History
Utilization Management Nurse
Optum (formally Epic Management LP)
12.2022 - Current
- Referred cases to secondary review for failure to meet MCG, Medicare and health plan criteria.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Review and process denial letters ensuring the letter is proper grade level and meets Medicare and health plan standards.
Utilization Management Nurse
EPIC Management LP
11.2012 - 12.2022
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Referred cases to secondary review for failure to meet CMS, health plan and MCG criteria.
Clinic LVN
Epic Management LP
09.1994 - 11.2012
- Performed nursing assessments and collected patient medical histories to help determine proper diagnosis.
- Cared for clinic patients by administering medications and treatments for various conditions.
- Documented patient medical histories, current symptoms and vitals.
- Administered medications and therapies in accordance with physicians orders.
Education
Vocational Nurse - Nursing
Redlands Adult School
Redlands, CA09.1994
Skills
- Utilization Review
- Microsoft Office
- Critical Thinking
- Ethical practice
- Healthcare regulations
- Medical necessity evaluation
- Interpersonal and written communication
Timeline
Utilization Management Nurse
Optum (formally Epic Management LP)
12.2022 - Current
Utilization Management Nurse
EPIC Management LP
11.2012 - 12.2022
Clinic LVN
Epic Management LP
09.1994 - 11.2012
Vocational Nurse - Nursing
Redlands Adult School
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