Description
I have been a nurse since 1999. I worked as an LPN from 1999 until 2009 when I graduated from the University of Phoenix with my BSN. I was a part of the first graduating class of the LPN to BSN bridge at the University of Phoenix. In the clinical setting I have worked in the long-term care, sub-acute and medical-surgical settings. I began my career in managed care at TriWest Healthcare Alliance as a prior authorization nurse and telephonic utilization review nurse. When my husband and I moved to Florence, AZ I moved into the AHCCCS and SNP arena, Over the years I have become very well versed in AHCCCS, Medicare, InterQual and Milliman Criteria. I have memorized AHCCCS, Medicare National Coverage Determination and Local Coverage Determination Criteria and Policies. I am the resource person for all questions regarding AHCCCS and Medicare covered benefits and indications of coverage. I have created tools to increase productivity and consistency for nurse and medical director review. I have also created tools for denial letters for productivity and consistency, the letters I created meet the eighth (8th) grade language Medicare requirement. All of my tools are CPT code driven for ease of use. In the AHCCCS arena I created a tool for denial letters that met the sixth (6th) grade level requirement. My letters passed an AHCCCS letter audit for two (2) quarters. The tool I created was used after I resigned my position. I have 6 years experience as a long-term care floor nurse. I have 3 years in the sub-acute setting, 8 months working the medical-surgical floor. I also have 10 years prior authorization nurse review and concurrent /utilization review for Tricare, AHCCCS, and Medicare. At one-time I was the prior authorization manager, supervisor and prior authorization production nurse. I resigned my position as manager/supervisor over the prior authorization nurses and representatives and resumed my roll as prior authorization production nurse. I found all three roles to be too demanding, I was replaced by a prior authorization nurse manager and a prior authorization representative manager. I broke production nurse review production quotas and accuracy standards.
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