DENISE SIMMS, RN

• Performed prospective, concurrent, and retrospective utilization reviews for specialty infusions and injectables, validating eligibility, network coverage, site‑of‑care, and medical‑necessity criteria.

• Applied MCG and payer medical policy to determine benefit alignment, clinical appropriateness, and authorization requirements for IVIG, HIV injectables, OPAT antimicrobials, and biologics.

• Applied benefit application criteria to authorization workflows, ensuring alignment with coverage determinations.

• Reviewed out‑of‑network requests for medical necessity and benefit alignment, collaborating with Medical Directors to support defensible determinations.

• Managed a remote caseload of 50–65 monthly prior authorizations, meeting timeliness standards and achieving a 90% approval rate.

• Led remote peer‑to‑peer reviews and collaborated with Medical Directors and Claims to overturn denials.

• Maintained real‑time documentation in Epic and payer portals to ensure audit readiness and compliance.

• Supported quality improvement and accreditation readiness by maintaining audit‑ready documentation and contributing to UM timeliness standards.

• Coordinated vendor and patient‑assistance workflows, enrolling 100+ patients in manufacturer/copay programs; reducing out‑of‑pocket costs by 40%.

• Communicated effectively in a hybrid environment, managing prior authorization requests, virtual escalations, and cross‑functional case coordination.

• Reviewed clinical indicators and documentation to support accurate admission vs. observation determinations.

• Performed real‑time utilization assessments during ED throughput monitoring.

• Collaborated with ED physicians and supervisors to coordinate escalations and maintain patient flow.

• Conducted root‑cause analyses on behavioral‑health cases to identify documentation gaps.

• Led Joint Commission readiness audits and documentation‑integrity reviews to ensure regulatory alignment.

• Used Epic dashboards and performance metrics to optimize workflows and improve throughput.

• Reviewed patient charts to ensure completeness, regulatory alignment, and Joint Commission (JCAHO) compliance.

• Redesigned ED workflows and performance metrics to improve throughput and reduce LWBS rates.

• Directed shift‑level operations to ensure accurate triage documentation, acuity capture, and compliant utilization management.

• Collaborated across multidisciplinary teams to maintain safe patient flow, reduce delays, and support efficient care transitions.

• Completed structured case reviews applying documentation standards, clinical indicators, and coding alignment.
• Built UM determination templates to strengthen defensible medical‑necessity rationale.
• Improved diagnosis‑to‑treatment linkage for payer review scenarios.

• Analyzed National and Local Coverage Determinations to understand benefit criteria and coverage limitations.
• Created a quick‑reference guide for applying NCD/LCD rules to prospective and concurrent reviews.
• Strengthened benefit‑interpretation skills for authorization and appeals workflows.

• Practiced applying InterQual criteria to sample admission, observation, and outpatient scenarios.
• Compared InterQual vs. MCG pathways to improve cross‑criteria competency.
• Developed mock UM case summaries demonstrating criteria‑based decision making.