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DJ@deangelajames
Experienced Registered Nurse specializing in Utilization Review and Case Management.
United StatesI am a highly skilled and results-oriented Registered Nurse with over 15 years of experience, including 8 years specializing in Utilization Review and Case Management within acute care and managed care settings. My proficiency in InterQual criteria and healthcare technology has enabled me to ensure compliance, optimize patient care, and improve operational efficiency. As a Certified Case Manager (CCM) and InterQual Certified Instructor, I am recognized for my excellent communication skills, attention to detail, and collaborative approach to patient care and process improvement.
In my current role as a Utilization Review Nurse at GuideWell/Florida Blue Medicare, I perform comprehensive admission reviews and continued stay reviews for Managed Medicare members. I utilize InterQual criteria to validate clinical decisions and ensure compliance with CMS, NCQA, and URAC standards. I actively participate in team meetings to support interdepartmental coordination and process refinement, and I have contributed to workforce development by providing onboarding support and training for new nurse reviewers.
Throughout my career, I have demonstrated a commitment to quality assurance and process improvement. I have trained numerous newly hired nurses and have been involved in high-level organizational meetings to enhance compliance and operational standards. My extensive experience in various healthcare settings has equipped me with the skills necessary to excel in patient advocacy and care coordination, ensuring that patients receive the best possible care.
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Work history, roles, and key accomplishments
GuideWell/Florida Blue Medicare
Mar 2020 - Present (5 years 8 months)
Performed comprehensive Day 1 admission reviews and continued stay reviews for Managed Medicare members, utilizing InterQual criteria to validate clinical decisions and ensure compliance with CMS, NCQA, and URAC standards. Served as a subject matter expert and resource in InterQual application and case documentation, providing onboarding support and team orientation to new nurse reviewers.
Aerotek Solutions
Aug 2019 - Present (6 years 3 months)
Performed comprehensive day 1 reviews for Managed Medicare Members and communicated case determinations (approvals/denials) to providers. Utilized Jiva Care systems and Microsoft Suite proficiently, while consistently adhering to standard operating procedures.
Boca Raton Regional Hospital
Apr 2019 - Present (6 years 7 months)
Performed comprehensive Day 1 and concurrent reviews on various payers for orthopedic, surgical, oncology, telemetry, ICU, Stepdown, and Neurological patients, utilizing Interqual to confirm ordered level of care. Trained several newly hired Utilization Review nurses on InterQual use and application, and was involved in high-level organizational meetings regarding surgical patient processes.
Bethesda Hospital
May 2018 - Present (7 years 6 months)
Performed comprehensive Day 1, retroactive, and continued stay reviews on various payers for Medical Surgical, Telemetry, Oncology, Orthopedic, and ICU patients, utilizing Maxys and Right Fax to communicate findings. Managed initial commercial payer denial processes and collaborated closely with multidisciplinary teams for care coordination.
Confier Health Solutions
Jan 2017 - Present (8 years 10 months)
Performed admission reviews for a wide range of patient types across numerous hospitals remotely, utilizing InterQual extensively to confirm criteria met for ordered patient designations. Wrote concise summaries highlighting severity of illness and intensity of service, correlating to InterQual requirements.
John Hopkins All Children’s Hospital
Jul 2007 - Present (18 years 4 months)
Provided evidence-based and comprehensive nursing care to Pediatric and Neonatal patients, gaining extensive knowledge of medical procedures and terminology. Served as a Super User for the Cerner documentation program in the Neonatal Intensive Care unit, which involved staff training and on-unit assistance.
Degrees, certifications, and relevant coursework
FUBachelor of Science in Nursing, Nursing
Completed a comprehensive Bachelor of Science in Nursing program. Gained foundational knowledge and practical skills essential for a nursing career.
Software and tools used professionally
United StatesYou can contact Deangela and 90k+ other talented remote workers on Himalayas.
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