Lisa Browne
Shermans Dale
Summary
Seasoned Director of Utilization Review with background in ensuring healthcare services are both cost effective and meet patient needs. Specialize in implementing strategies for improved utilization review processes, reducing denial rates, and enhancing patient satisfaction. Strengths include effective communication skills, ability to lead teams towards operational excellence, and knowledge in regulatory standards compliance. Past roles have led to significant improvements in process efficiency and healthcare delivery outcomes.
Overview
26
26
years of professional experience
Work History
Director of Utilization Review
Homeland Center
Harrisburg
06.2017 - Current
- Coordinated interdisciplinary team meetings to discuss patient care strategies.
- Reviewed requests for authorization using appropriate criteria sets such as InterQual or MCG Care Guidelines.
- Analyzed medical records for adherence to standards of care and appropriateness.
- Trained staff on utilization review protocols and best practices, enhancing team competency.
- Implemented quality assurance measures to enhance review accuracy and consistency.
- Monitored quality assurance activities for utilization reviews.
- Collaborated with insurance providers to streamline authorization processes.
- Verified compliance of utilization reviews with state and federal regulations and industry standards.
- Provided guidance on compliance issues related to utilization review regulations.
- Developed and implemented utilization review policies and procedures.
- Participated in interdisciplinary meetings involving case management, social work, physicians, nurses, and other members of the health care team.
- Created system to track progress of utilization reviews, facilitating timely completion.
- Managed external vendors providing utilization review services.
- Trained new employees on utilization review processes and regulations.
- Coordinated with medical staff, providers, and other healthcare professionals to ensure proper coding and documentation of services provided.
- Identified potential opportunities for cost savings by analyzing trends in service usage patterns within the organization's network of providers.
- Analyzed data from Medical Assistance outcomes to measure program effectiveness. Conducted regular weekly audits of utilization review processes and MDS completion to identify areas for improvement.
- Provided feedback to healthcare providers on clinical documentation improvement to support utilization review.
- Ensured awareness of evolving healthcare standards and practices.
- Maintained up-to-date knowledge of changes in healthcare regulations, policies, and evidence-based practices. Reviewed PA Pre-Admission Screening Resident Review (PA-PASRR-ID to determine facility compliance with OBRA.
- Administered fiscal operations for accounting, budget planning, authorizing expenditures and coordinating reporting.
- Developed medical programs that promoted community health and research.
- Developed medical programs that promoted community health and research.
Clinical Reimbursement Coordinator
Stonebridge Health and Rehab Facility
Duncannon
07.2013 - 05.2016
- Processed insurance claims for patient services, ensuring timely reimbursements and minimizing delays.
- Collaborated with finance department to reconcile accounts and manage payment postings.
- Maintained accurate patient records in electronic health systems for reimbursement tracking.
- Educated staff on reimbursement policies and procedures to enhance workflow efficiency.
- Monitored healthcare regulations impacting reimbursement processes to maintain compliance and mitigate risks.
- Protected patient data confidentiality and integrity to comply with legal and ethical standards.
- Coded patient care records to provide accurate information for billing.
- Provided guidance on proper coding techniques according to ICD-10 guidelines.
- Submitted electronic and paper claims to insurance companies within established timelines.
- Maintained accurate records of all reimbursements processed in compliance with HIPAA regulations.
- Processed requests for prior authorization from insurance companies.
- Attended meetings with internal stakeholders to discuss current challenges related to reimbursements.
- Resolved customer inquiries regarding reimbursement status and payment discrepancies.
- Conducted research into industry trends and best practices to identify improvements in existing reimbursement processes.
- Attended seminars to remain up-to-date with coding guidelines and reimbursement requirements.
- Worked with billing department to reduce contract implementation errors.
- Verified clients' insurance claims coverage by coordinating with providers.
- Offered subject matter expertise on employment regulations, compensation policies and personnel management procedures to optimize internal structures.
Registered Nurse Assessment Coordinator/Supervisor
Thornwald Home
Carlisle
05.2007 - 02.2013
- Conducted comprehensive assessments for residents' health and care needs.
- Collaborated with interdisciplinary teams to develop individualized care plans.
- Facilitated staff training on assessment protocols and documentation practices.
- Reviewed medical records to ensure compliance with regulatory standards.
- Implemented quality improvement initiatives to enhance patient care services.
- Coordinated resident admissions and discharges with healthcare providers.
- Monitored changes in residents' conditions and adjusted care plans accordingly.
- Assisted in resolving family concerns regarding resident care and treatment options.
- Collaborated with multidisciplinary teams to ensure optimal patient outcomes.
- Ensured that nursing documentation accurately reflects the plan of care for each patient served by the facility.
- Conducted patient assessments to identify individual needs and develop care plans.
- Developed protocols for assessing the physical status of all newly admitted patients.
- Demonstrated knowledge of current trends in nursing practice related to assessment techniques.
- Maintained accurate medical records for patients according to established policies and procedures.
- Monitored compliance with regulatory standards related to quality assurance and improvement initiatives.
- Identified potential risks associated with specific conditions or treatments based on assessment findings.
- Reviewed medical chart and requested appointments, prescriptions and consultations for urgent needs.
- Attended educational workshops to maintain current competency and licensure in nursing specialty.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Case Manager
United Hospice
Macon
03.2000 - 02.2007
- Coordinated patient care plans with interdisciplinary teams and families to ensure comprehensive support.
- Facilitated communication between healthcare providers and patients for effective support.
- Developed educational resources for patients and families on hospice services to enhance understanding and engagement.
- Managed case documentation in electronic health record systems efficiently.
- Advocated for patients' rights and preferences in care decisions consistently.
- Conducted regular follow-ups to ensure adherence to care plans and services provided.
- Provided case management services including intake, assessment, crisis intervention, advocacy, referral and monitoring of families.
- Monitored client progress through regular follow-up contacts.
- Maintained accurate case records and documentation according to agency guidelines.
- Counseled clients on community resources to effectively address their needs and improve access to support.
- Participated in regular team meetings and in-house training sessions to boost group effectiveness.
- Provided referrals to appropriate health care providers or other community resources.
- Adhered to ethical principles and standards to protect clients' confidential information.
- Assisted with applications for government benefits such as Medicaid or Social Security Disability Insurance.
- Coordinated support services and optimized communication between healthcare workers and patients.
- Transitioned clients to different providers based on progress or needs.
Education
Associate of Science - Nursing
Washing Hospital School of Nursing
Washington, PA08-1986
Skills
- Utilization review
- Utilization management
- InterQual criteria
- Utilization analytics
- Quality assurance
- Quality improvement
- Compliance verification
- Regulatory requirements
- Regulatory knowledge
- Data analysis
- Medicaid
- Medicare
- Documentation review
- Patient advocacy
- Care coordination
- Effective communication
- Team collaboration
- Problem solving
- Time management
- Healthcare leadership
- Conflict resolution
- Active listening
Timeline
Director of Utilization Review
Homeland Center
06.2017 - Current
Clinical Reimbursement Coordinator
Stonebridge Health and Rehab Facility
07.2013 - 05.2016
Registered Nurse Assessment Coordinator/Supervisor
Thornwald Home
05.2007 - 02.2013
Case Manager
United Hospice
03.2000 - 02.2007
Associate of Science - Nursing
Washing Hospital School of Nursing