Frances Patti
Staten Island,United States
Summary
Experienced healthcare professional with a solid background in both inpatient and outpatient telephonic preauthorizations, and inpatient utilization concurrent review nursing. Ensured compliance with care standards and facilitated effective patient outcomes. Demonstrated strong analytical skills and attention to detail in reviewing medical records and collaborating with healthcare teams. Developed expertise in evaluating patient records and collaborating with medical teams to ensure optimal care. Seeking to leverage transferable skills in a new and challenging field. Known for reliability and adaptability in dynamic healthcare environments, with expertise in case management and patient assessment. Committed to improving patient care through diligent and thorough reviews.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Inpatient Concurrent Review Nurse
NYC Health & Hospital Corpor/Jacobi Medical Center
02.2008 - 10.2024
- Performed comprehensive analyses of patient medical histories.
- Analyzed patient care protocols for correctness and performance.
- Team up with medical staff to achieve exceptional patient care outcomes.
- Incorporated evidence-based methodologies into clinical decision making.
- Kept abreast of evolving medical guidelines and industry standards.
- Conveyed review outcomes to relevant parties.
- Ensured adherence to compliance regulations and maintained ethical conduct.
- Participated in enhancing quality improvement processes.
- Demonstrated proficiency in interpreting national healthcare policies.
- Accurately adhered to InterQual and MCG criteria protocols.
- Reviewed and referred Lack of Medical Necessity Denial cases for peer review with the Attending.
- Select candidates with conditions such as diabetes mellitus, asthma, HIV, renal and liver diseases, heart conditions, COPD, cancer or catastrophic occurrences for case management.
Nurse Case Manager
Community Choice Health Plan
09.2007 - 01.2008
- Designed a structured health initiative focusing on selecting target populations and evaluating interventions for quality and results.
- Overhauled and executed tracking systems, provider communication letters.
- Managed and executed discharge planning.
- Coordinate patient treatment across various care stages.
- Engaged in initiatives to enhance quality standards.
- Monitored Outpatient, Ancillary, and Rehabilitative Services.
- Managed community outreach programs and scheduled transportation solutions.
- Used trigger diagnoses to determine eligibility for case management services.
- Identified high-risk individuals through thorough Health Risk Assessment analysis.
- Facilitated thorough case management for patients seeking assistance.
- Facilitated effective communication among healthcare professionals for optimal patient outcomes.
- Assess patient needs and develop individualized care plans.
- Monitor patient progress and adjust care plans as needed.
- Facilitate timely and accurate delivery of necessary healthcare services.
- Communcated with insurance providers for approval of services.
- Ensured patients received exceptional quality of care.
- Monitored new developments in healthcare laws and regulations.
Concurrent Review Nurse
HIP USA
08.2006 - 09.2007
- Extensive understanding of commercial, Medicare, and Medicaid regulations for NY.
- Analyzed members' diagnoses and inpatient care using DRG, CPT, and ICD coding.
- Execute concurrent review calls within and outside of the network.
- Utilize Medicare/Medicaid guidelines, policy procedures, InterQual Criteria and Milliman and Robertson guidelines approved services for members both inpatient and outpatient
- Facilitate patient discharge through the identification of appropriate care alternatives.
- Reviews, and assist rep negotiations toward favorable and competitive rates with providers when required
- Responsible for assessment of hospital services and identifying discharge plan needs, management of active cases in acute and sub-acute levels of care, and coordinating delivery of health care services for members
- Authorizing services per the contract, along with timely entry of clinical notes and referrals as required to the Medical Director
- Interacts regularly with medical directors, clinical managers, team managers and other team members
- Responsible for analysis of individual complex cases acting to resolve in a quality focused and timely manner, analysis of utilization patterns.
- Reviewed clinical aspects of patient hospitalizations.
- Follow established healthcare guidelines.
- Work with healthcare providers.
- Suggested effective care management strategies.
- Logged conclusions and determinations.
- Evaluated treatment efficacy by monitoring outcomes.
- Follow established processes and protocols.
Inpatient Utilization Concurrent Review Nurse
UHP of NJ
04.2003 - 08.2006
- In-depth understanding of NY and NJ's Medicare and Medicaid regulations.
- Carries out simultaneous clinical assessments for in-network and out-of-network inpatient cases.
- Conducted comprehensive review for accurate diagnostic coding.
- Facilitated cooperation among medical personnel and healthcare providers.
- Verified adherence to policies in inpatient case clinical reviews.
- Analyzed effectiveness of current treatments by tracking patient improvements.
- Carefully recorded outcomes and suggestions.
- Provide education on healthcare processes.
- Led team with expertise and direction in Precert Department.
- Implemented InterQual, Milliman & Robertson guidelines for inpatient and outpatient care services.
- Assessed hospital services and identified discharge plan needs.
- Analyzed individual complex cases ensuring timely and quality-focused resolutions.
- Collaborated frequently with team managers and other staff members.
- Reviewed and supported negotiation efforts for favorable provider pricing.
- Evaluated and directed suitable cases for denial.
Inpatient Utilization Concurrent Review Nurse
AmeriChoice of NJ
05.2000 - 04.2003
- Performs concurrent reviews through telephonic communication across networks.
- Apply clinical knowledge of Millman & Robinson and InterQual to approve services.
- Utilize corrective DRG, CPT, and ICD coding for accurate medical service documentation.
- Conduct concurrent clinical evaluations of inpatient cases.
- Work with healthcare providers to guarantee suitable care level.
- Reviewed and recommended actions for inpatient records.
- Maintain strict adherence to established company protocols.
- Offered strategic leadership and insights within the Prior Auth Department.
- Ensured compliance with Medicare/Medicaid guidelines, InterQual Criteria, Milliman and Robertson guidelines, policy and procedures.
- Assessed hospital services and identified discharge plan needs.
- Contribute to provider relations by securing advantageous rates during negotiations as required.
- Analyzed usage trends to manage specific case complexities efficiently.
- Collaborated routinely with various medical and managerial professionals.
- Referred relevant cases for further review or denial.
Inpatient and Outpatient Prior Auth Nurse
Cigna Healthcare
01.2000 - 05.2000
- Ensured accuracy of information related to the medical necessity for inpatient hospitalization and selected ambulatory procedures.
- Approved medical services by leveraging InterQual criteria and clinical knowledge.
- Performed evaluations of inpatient diagnoses with corresponding medical and surgical procedures.
- Initiate prior authorization requests with insurance companies.
- Collaborate with healthcare providers to gather necessary clinical information
- Ensure timely approval of prior authorization requests
- Assist in resolving any authorization denials or delays
- Maintain accurate documentation of prior authorization process.
- Communicate with patients regarding prior authorization status
- Work closely with pharmacy team to obtain medication prior authorizations
- Coordinate with case managers for complex authorization cases
- Maintained up-to-date knowledge of insurance guidelines and policies.
- Directed Prior Auth team with expert guidance.
- Collaborated with medical professionals, disease case managers, social workers, supervisors and physicians to manage complex cases.
- Performed eligibility reviews via telephone for both in-network and out-of-network services.
- Achieves favorable provider rates by facilitating negotiations.
Nurse Case Manager
CORAM RNET
10.1998 - 12.1999
- Managed all intake data comprehensively while starting relevant services within the system.
- Acquire complete and correct data regarding services.
- Established and maintained direct communication with members, families, health care providers, and other participant resources.
- Compiled an exhaustive problem list by integrating information sourced from participants, relatives, doctors and other health care personnel.
- Developed action plans incorporating participant's needs while navigating benefit constraints.
- Analyzed plan restrictions, contributing to uninterrupted patient care.
- Supervised seamless patient care processes.
- Design tailored healthcare strategies.
- Collaborate with healthcare team.
- Provide patient education.
- Executed assessments.
- Monitored effectiveness of therapeutic interventions.
- Ensure efficient handling of patient referrals.
- Promoted effective dialogue.
- Sustain high-quality service performance.
- Upheld precise documentation.
Education
Diploma - Nursing
Monmouth County Vocational School of Nursing
Long Branch, NJ01.1990
Skills
- Utilization Care Management
- Nursing
- Licensed Practical Nurse/Licensed Vocational Nurse
- Knowledge of DRG
- Commercial Health Plans
- Medicaid and Medicare
- Pediatrics, PICU, and NICU
- Case Management
- COPD (Chronic Obstructive Pulmonary Disease)
- Diabetes
- Discharge Plans
- Medical Equipment
- International Classification of Diseases (ICD)
- Negotiation Skills
- Surgical Procedures
- Healthcare
- Home Care
- Dermatology
- Microsoft Works
- Pediatrics
- Phlebotomy
- Establish Priorities
- Risk Management
- Typing
- Microsoft Windows Operating System
- Patient Care
- Microsoft Internet Explorer Browser
- Certified Case Manager (CCM)
- Program Planning
- Community Support
- Durable Medical Equipment
- Quality Metrics
- Customer Support/Service
- Component Selection
- Purchasing/Procurement
- Outpatient Care
- Time Management
- Analysis Skills
- Team Lead/Manager
- Hospital
- Diagnosis-Related Group (DRG)
- Pattern Analysis
- Medical Diagnosis
- Service Delivery
- Needs Assessment
- Current Procedural Terminology (CPT)
- Provider Relations
- Quality of Care
- Medical Treatment
- Disease
- People Management
- Medical Records
- Government
- Healthcare Providers
- Documentation Plan
- Documentation
- Maternal/Child Nursing
- Computer Skills
- QuadraMed
- Microsoft Excel
- EPIC
- Clinical Information
- Data Collection
- Clinical Nursing
- Clinical Medicine
- Behavioral Health
- Telephone Skills
- Health Insurance
- Nursing Credentials
Certification
- New York and New Jersey Licensor as a Licensed Practical Nurse
- CPR Basic Life Support
- Diabetic Treatment certified
- Phlebotomy certified
Personal Information
Title: Inpatient Concurrent Review Nurse
Workauthorization
I am authorized to work in the following countries: United States
Timeline
Inpatient Concurrent Review Nurse
NYC Health & Hospital Corpor/Jacobi Medical Center
02.2008 - 10.2024
Nurse Case Manager
Community Choice Health Plan
09.2007 - 01.2008
Concurrent Review Nurse
HIP USA
08.2006 - 09.2007
Inpatient Utilization Concurrent Review Nurse
UHP of NJ
04.2003 - 08.2006
Inpatient Utilization Concurrent Review Nurse
AmeriChoice of NJ
05.2000 - 04.2003
Inpatient and Outpatient Prior Auth Nurse
Cigna Healthcare
01.2000 - 05.2000
Nurse Case Manager
CORAM RNET
10.1998 - 12.1999
Diploma - Nursing
Monmouth County Vocational School of Nursing
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