Beverly Yawn
Dayton
Summary
Organized and motivated employee eager to apply time management and organizational skills in various environments. Seeking new opportunities to expand skills while facilitating company growth.
Experienced with utilization review, case management, and team leadership. Utilizes strategic planning and process improvement to enhance performance and compliance. Track record of effective communication and problem-solving in high-pressure environments.
Overview
12
12
years of professional experience
Work History
Director of Utilization Management
Cross Creek Hospital
10.2023 - 09.2025
- Assigned new cases based on facility-specific caseload process. Recommended caseload assignment to Physician or Unit for most efficient use of time and efforts.
- Pulled Admission and Discharge Register Reports daily
- Attended daily meetings with clinical services, administration and department heads to discuss newly denied days, scheduled Peer-to-Peer reviews, Pending pre-certs, documentation concerns, Internal Medicare audits, discharge of patients
- Assigned UM staff to attend scheduled treatment team meetings and perform as an active member of the interdisciplinary team
- Weekly audits of authorizations, denials, documentation, appeals and payor correspondence.
- Collaborated with Outpatient Coordinator to assure OP authorizations are current for PHP and IOP patients.
- Worked closely with the Business Office Director and Chief Financial Officer on denials and appeals processes
- Quarterly UM Committee Meetings
- Weekly Denial Log Meetings
- Monthly Corporate “Spotlight Report”
- Instrumental in implementation of new processes to bring UM department under budget
- Compliant with State and Federal statutes, laws, regulations, internal policies and procedures and guidelines
- Supervised utilization management processes, ensuring compliance with healthcare regulations and standards.
- Led team in reviewing patient care plans, optimizing resource allocation for improved outcomes.
- Collaborated with interdisciplinary teams to enhance patient care coordination and service delivery efficiency.
- Implemented strategic initiatives to streamline operations, reducing review turnaround times significantly.
- Developed training programs for staff, enhancing knowledge of utilization management protocols and best practices.
- Conducted regular performance evaluations, providing mentorship and guidance to improve team productivity.
- Presented findings to senior leadership, influencing policy decisions related to resource management and patient care strategies.
- Maximized efficiency of case reviews through the development and implementation of standardized review procedures.
- Devised innovative solutions to address gaps in care or inefficiencies within the utilization management process.
Director of Utilization Review and Case Management
The Hospital at Westlake Medical Center, Arise Austin Medical
02.2022 - 06.2023
- Determined medical necessity and cost-effectiveness of services through utilization review processes as directed by InterQual and Milliman's criteria.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Collaborated with Utilization Review Committees in group meetings to identify issues and find cost-effective solutions.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Referred patients to specialized health resources or community agencies to furnish additional assistance.
- Achieved departmental goals and objectives by instituting new processes and standards for in-patient care.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Checked documentation for appropriate coding, catching errors and making revisions.
- I recovered over $1.2 million in previously denied claims in the first 6 months of the employment.
- I was instrumental in identifying issues with claims and assuring a 97% clean claim rate under my direction.
- Developed and implemented utilization management protocols to enhance operational efficiency.
Case Manager/Clinical Nurse Reviewer
Blue Cross Blue Shield of Tennessee
02.2017 - 02.2022
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system. Achieved departmental goals and objectives by instituting new processes and standards for in-patient care. Collaborated with health groups to plan or implement programs designed to improve overall health of communities. Interpreted and evaluated diagnostic tests to identify and assess patient's Summary Skills Experience condition. I participated in several collaborative efforts to improve efficiency and effectiveness of the review process. I sat on several committees which discussed ways to increase member satisfaction, employee retention and proficiency.
- I worked for a Temporary Agency at BCBT (2/2017-5/2018) prior to being offered a full-time position with BCBST.
- Coordinated care plans for diverse populations, ensuring comprehensive support and timely intervention.
- Facilitated communication between clients and healthcare providers to enhance service delivery and outcomes.
- Implemented process improvements that streamlined case handling procedures, increasing operational efficiency.
- Collaborated with multidisciplinary teams to address complex cases, enhancing holistic care strategies.
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
Staff RN Med/Surg Unit/ICU PRN
Rhea Medical Center
09.2016 - 11.2019
- Administered medications, tracked dosages and documented patient conditions. Explained treatment procedures, medication side effects, special diets and physician instructions to patients. Performed nursing rounds to complete scheduled tasks and interact with patients. Prioritized patient care assignments based on patient conditions to achieve optimal outcomes. Collaborated with interdisciplinary healthcare professionals to create, implement and adapt individualized care plans. Mentored new nurses on practices and procedures to drive patient outcome goals. Instructed patients, families and caregivers on diagnoses, chronic disease management and medication self-management.
- Administered patient care plans, ensuring adherence to established protocols and standards.
- Collaborated with multidisciplinary teams to enhance patient outcomes and streamline communication.
- Evaluated patient progress, adjusting care strategies based on clinical assessments and feedback.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Implemented medication and IV administration, catheter insertion, and airway management.
Staff RN/ LPN Supervisor
LifeCare of Ooltewah Rehabilitation Center
03.2014 - 09.2019
- Collaborated with interdisciplinary healthcare professionals to create, implement and adapt individualized care plans. Maintained reports to provide oncoming shift with full patient status. Mentored new nurses on practices and procedures to drive patient outcome goals. Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care. Reviewed physician orders and participated in medication management to optimize patient safety. Case Management and Clinical Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care. Coordinated care with charge nurse and other staff through daily communication. Conducted patient assessments and diagnostic tests to provide physician with important patient health information. Developed care plans complete with effective nursing measures to improve patients' mental and physical health.
- Administered patient care plans, ensuring adherence to individualized treatment protocols.
- Coordinated care with multidisciplinary teams to optimize patient outcomes and streamline communication.
- Educated patients and families on health management strategies, fostering informed decision-making.
- Implemented infection control procedures, enhancing safety standards throughout the rehabilitation center.
- Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Consistently maintained accurate documentation of all relevant information related to patient progress, treatments administered and other pertinent data.
Education
Associate of Science - Nursing
Chattanooga State Community College
Chattanooga, TN05.2016
Skills
- Proficient in care planning and coordination
- Effective solution development
- Comprehensive case coordination
- Interdisciplinary care management
- Clinical utilization review
- Healthcare team management
- Employee development and guidance
- Effective clinical decision-making
Timeline
Director of Utilization Management
Cross Creek Hospital
10.2023 - 09.2025
Director of Utilization Review and Case Management
The Hospital at Westlake Medical Center, Arise Austin Medical
02.2022 - 06.2023
Case Manager/Clinical Nurse Reviewer
Blue Cross Blue Shield of Tennessee
02.2017 - 02.2022
Staff RN Med/Surg Unit/ICU PRN
Rhea Medical Center
09.2016 - 11.2019
Staff RN/ LPN Supervisor
LifeCare of Ooltewah Rehabilitation Center
03.2014 - 09.2019
Associate of Science - Nursing
Chattanooga State Community College
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