Dynamic Utilization Review Nurse with Aetna Better Health of Illinois, skilled in InterQual criteria and patient advocacy. Proven track record in enhancing review processes and ensuring compliance with utilization management guidelines. Adept at clinical assessment and fostering collaboration among multidisciplinary teams to optimize patient care outcomes.
Overview
2026
2026
years of professional experience
Work History
Utilization Review Nurse
Aetna Better Health of Illinois
Chicago, IL
12.2020 - 01.2026
Conducted comprehensive reviews of medical necessity and appropriateness of services.
Collaborated with healthcare providers to ensure compliance with utilization management guidelines.
Evaluated clinical documentation for accuracy and adherence to policy standards.
Developed and implemented strategies for improving review processes and outcomes.
Reviewed claims for all hospitals that were out of network and/or out of state.
Recieved 100% on all quarterly audits
Case Manager/Utilization Review Nurse
IlliniCare
Westmont, IL
2017 - 2020
Coordinated comprehensive care plans for clients, ensuring access to necessary resources and services.
Advocated for clients' needs, facilitating communication between healthcare providers and families.
Assessed client eligibility for programs, streamlining intake processes for improved efficiency.
Collaborated with multidisciplinary teams to develop tailored intervention strategies and goals.
Managed assignment of high-risk clientele with severe psychological dianoses.
Reviewed clinical documentation of inpatient admissions for medical necessity.
RN Nurse Trainer
Association for Individual Development
Aurora, IL
2013 - 2017
Medication Administration Training: Teach DSPs and caregivers how to safely supervise and administer medication according to established medical guidelines.
Compliance & Record-Keeping: Ensure all medical documentation, Health Risk Screenings, and Medication Administration Records (MARs) align with regulatory standards.
Clinical Oversight: Conduct annual health assessments, develop client service plans of care, and liaise with doctors and pharmacists.
Caregiver Evaluation: Assess caregiver competency through written tests and hands-on skill evaluations.
Managed medication education and compliance of over 100 employees.
Utilization Review Nurse at Cedar Crest Hospital & Residential Treatment CenterUtilization Review Nurse at Cedar Crest Hospital & Residential Treatment Center