Lisa Laren

This position handles utilization of Florida Blue Medicare population; working with providers, facilities and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination if the delivery of quality care.

Conducts review for outpatient services including but not limited to imaging, surgeries, genetic testing, DME, home health as well as Part B medications

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services for medicare and commercial members in the acute care setting
• Tasks include but limited to escalating cases to MD review, high dollar case monitoring, MD rounds, assist with dc planning
• Meets and/or exceeds minimum case productivity metric requirements

• Review claims for prior services to determine medical necessity based on MCG & Humana Military policy & procedures
• Documented determination of medical necessity referred by automated edits and for cases where pre-auth was required but not obtained by applying guidelines to assure payment for only medically necessary and appropriate services
• Escalate cases for Physician Review when appropriate

• Reviewed clinical documentation to resolve denied claims based on Aetna guidelines & government regulations
• Performed utilization management assessments by telephone for American Health Holding (prior to merger with Aetna) for services that include, but not limited to acute, subacute LOC's, HH, diagnostics, in and outpatient surgeries, DME & diagnostics services based on MCG, InterQual & Aetna guidelines
• Consulted with medical directors when services failed criteria protocols
• Communicated denials to medical providers & initiated appeals process, when indicated
• Exceeded minimum productivity metric requirements

• Provided insurance companies with comprehensive utilization of health care benefits management & case management for hospitalization & other healthcare services
• Achieved high standard of care at minimal cost & fair reimbursement by providing clients with comprehensive utilization of health care benefits & case management
• Performed concurrent review of services as well as precertification review for services
• Negotiated out-of-network services

• Provided clinical nursing care to oncology & medical/surgical patients in Florida & upstate New York hospitals, as well as Travel Nurse for American Mobile & Cross Country Healthcare
• Served as Nursing Preceptor & earned Palm Beach County Preceptor of Excellence award