Samantha Keith, RN, CCM

• Utilization management nurse for Outpatient (SNF, DME, Home Health, Urgent Care Clinics, outpatient surgery) and Inpatient (IRF, LTAC, acute care) retro claims review and provider dispute appeals
• Applied critical thinking skills to assess complex medical cases and determine appropriate levels of care in accordance with industry benchmarks such as MCG guidelines
• Evaluated medical guidelines and benefit coverage to determine appropriateness of services for the states of CA, VA, NV, and AZ
• Assist inpatient team with determining appropriate level of care observation status vs. inpatient level of care

• Strong leader for nursing personnel assign to unit including overseeing LPN's, CNA's, and new RN's.
  
• Provides direct patient care/teaching to residents/family members in acute care setting
• Float to cover different assignments to Med-Surgical, Oncology, Orthopedics, Telemetry, Cardiac Step-Down, Neurological/Cardiac units, and occasionally assist in Emergency Room for 332 acute bed hospital
• Commutes to Mercy Hospital Booneville (25-bed Critical Access Hospital) serving rural communities as needed for supplemental staffing

Utilization Management RN- Post Acute covering the Central Region (OK, AR, MO, and KS). Collaborate with other healthcare givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria and Milliman (MCG) .

• Manage network participation, care with specialty networks, care with DME providers, and transfers to alternative levels of care using knowledge of benefit plan design
• Recommend services for Humana Plan members utilizing care alternatives within the community and nationally
• Identify potentially unnecessary services and care delivery systems, and recommend alternatives if appropriate by analyzing clinical protocols
• Examine clinical programs information to identify members for specific case management and/or disease management activities or interventions by utilizing established screening criteria
• Conduct preadmission and concurrent reviews for LTAC's, Acute Rehabilitation Facility, and Skilled Nursing Facility including assisting with discharge planning
• On Call Nurse duties one weekend a month and occasionally holidays handling QIO discharge Expedited Appeals for hospital, LTAC, IRF, and SNF's. On call duties also include SNF admission preauthorization requests and handling any calls that come through the on call services phone

• Serves as a senior Medicare Analysts, compliance nurse, and utilization review nurse
• Assesses the member's needs to determine the best quality care and support over the continuum of care to achieve positive clinical outcomes and lower costs by using standard evidence-based, decision support criteria guidelines
• Provide clinical consultation and guidance to centers to assist in determining medical appropriateness of inpatient Medicare coverage and utilization, appropriate payer sources including Managed care plans, Coordination of Benefits, and case management
• Assist the Medicare Call Center to provide SNF coverage and eligibility guidance and education to 300 Skilled Nursing Facilities
• Collaborates with the interdisciplinary care team to identify solutions to ensure highest quality of care are provided to members
• Develop teaching and training materials for field based employees and MDS Coordinators on Medicare processes including Eligibility/Entitlement, Coverage, Certification, Supportive Skilled Documentation, SNF Denial Letters, and Original Medicare (Fee-For-Service) Appeals.
  
• Collaborate with management and Clinical Reimbursement to share trend analysis and identify Medicare utilization trends and potential compliance issues
• Track and provide training to 36-48 lead MDS Coordinators at a time during their 12 weeks orientation period
• Assist with Medicare Claims Analysts/Central Billing Office

• Provided direct care to patients in ICU, Cardiac Step-Down unit, Oncology, Orthopedics, Med-Surgical and Hospice Units
• Collaborated with interdisciplinary team in managing patient care
• Provided extensive discharge planning and education with patients and family
• Charge nurse duties and supervision of new RN's, LPN's and CNA's
• Function as a preceptor for ICU