Misty Mitchener

Experience

1. Utilization Management Rn

   Humana

   Nov 2023 — Present · FL, US

   Adhere and perform timely prospective reviews for services such as surgeries, high cost DME, imaging, Out of Network Specialist, etc requiring prior authorization from their insurance provider.• Follow the authorization process using established criteria as set forth by the payer or clinical guidelines.• Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services.• Refer to the treatment plan for clinical reviews in accordance with established criteria and or guidelines.• Serve as a resource to provide education to providers regarding payer policies and facilitate coordination of alternative treatment options.• Ensure and maintain effective communication regarding prior authorization status and determination to the clinical team and on occasion the patient.• Facilitate interdepartmental communication regarding authorization status in advance of the patient’s appointment.• Identify potential delays in treatment by reviewing the treatment plan and proactively communicate with the healthcare team and patient regarding the potential treatment barrier.• Maintain knowledge regarding payer reimbursement policies and clinical guidelines.

Education

• St. Petersburg College

  Registered Nursing/Registered Nurse

  2015