Lenore M.
Um Review Nurse @L.A. Care Health Plan
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WORK HISTORY
Um Review Nurse @L.A. Care Health Plan
Gilbert, AZ, US
UM review nurse reviews SNF admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
EDUCATION
DeVry University
Bachelor's degree, Health Information Technology Degree
ABOUT LENORE M.
Experienced Managed Care UM Nurse, with a demonstrated history of working in the hospital & health care industry. Wide range of skills and experience; able to make decisions, analyze risks, develop contingency plans; Create and manage a collaborative workflow process for UM referral management using criteria per Interqual and Milliman\'s guidelines. Professional History- Outpatient/Inpatient Utilization Management– 20 years -Outpatient/Inpatient Case Management – 20years- Retrospective Review– 20 years- Inter-Rater Reliability Survey / NCQA Assessment Survey - 5 years- Medical Claim Review – 10 years- Medi-Cal & Commercial Plan Member Appeals and Grievances -10 years- RHIT, Candidate Medical Claims Review Nurse reviewed claims for medical necessity, appropriate documentation Ability to code multiple record types with emphasis on accuracy using coding classification systems: ICD-9/ ICD-10 CM, CPT, and HCPCS. Knowledge of DRG for CMS - Medical and Surgical Clinical Acute Care Nursing -10 years
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