Summary
Overview
Work History
Education
Skills
PROFILE
Timeline
Generic

Renee Gibbs

Douglasville

Summary

Professional nurse with experience in utilization review. Strong focus on team collaboration and achieving results. Reliable and adaptable to changing needs. Skilled in medical record analysis, patient care evaluation, and compliance with healthcare regulations. Known for critical thinking, communication, and problem-solving abilities.

Overview

23
23
years of professional experience

Work History

Registered Nurse UM Consultant

CVS Health
01.2018 - Current
  • Evaluate the appropriateness of proposed treatments, procedures, or hospital stays based on established clinical guidelines and insurance policies.
  • Analyze medical records, including Medical History, Diagnosis, and treatment plan to assess the need for specific services.
  • Asses the medical necessity of services, ensuring that they are not duplicative or unnecessary.
  • Ensure members receive the necessary care while controlling costs and adhering to insurance guidelines.
  • Actively track UM denials, initiate Physician peer to peers, and process appeals.
  • Facilitate and advocate for options and services to meet the individuals benefit plan.
  • Collaborate with Attending Physicians as needed.
  • Utilize MCG or InterQual guidelines to make determinations.
  • Organize and Participates in weekly multidisciplinary meetings customized for each patient focused on quality of care and cost effectiveness.
  • Attend and participate in CM Monthly meetings, training's, and updates with CMO's guidelines.
  • Perform concurrent reviews , and retrospective reviews.
  • Complete trainings, tests, and skills for specific job.



Registered Nurse-Care Coordinator

Wellstar AMC
06.2016 - 11.2018
  • Performed reviews to evaluate the medical necessity, appropriateness and efficiency of healthcare services.
  • Performed timely medical necessity reviews to Insurance companies according to company policy.
  • Performed reviews on denials.
  • Initiated a successful Pilot on a Telemetry unit to decrease LOS for Medicare, Commercial, and Managed medicare members.
  • Participated in Daily rounds with the multidisciplinary teams to discuss treatment plan each patient.
  • Involved in discharge planning, helping patients transition to home or other care settings.
    Performed patient and family education on insurance benefits and treatment options.
  • Facilitated communication between clinical staff and insurance companies.
  • Participated in Dept training.
  • Preceptor


Registered Nurse- Care Coordinator

Northside Hospital
01.2015 - 01.2016

Registered Nurse – Case Management

Grady Health System
01.2008 - 01.2014

Registered Nurse - ICU

Grady Health System
01.2003 - 01.2008

Education

Master's Degree in Public Administration - Focus in Health Services

Keller School of Management
Atlanta, GA
04-2008

Associate’s Degree - Nursing

Olive Harvey College
Chicago, IL
01.1994

Bachelor of Science Degree - Biology

Rust College
Holly Springs, MS
01.1988

Associate of Science - Nursing

Olive Harvey College
Chicago, IL
05-1994

Skills

  • Clear written expression
  • Evaluate healthcare services for necessity and efficiency
  • Collaborative engagement with providers
  • Task execution with integrity

PROFILE

  • Competent in Case Management/Utilization review using Interqual / Milliman MCG guidelines.
  • Offer 34 years of experience in nursing with extensive experience in ICU, Telemetry, Trauma, Oncology, Mother baby, NICU, Behavioral Health, & Medical Surgical Units.
  • Exceptional background in defining and executing targeted nursing strategies and plans to maximize productivity, efficiency and quality.
  • Proven value, dedication as a reliable team leader.
  • Build solid working relationships with patients, physicians, internal staff, and providers.
  • Ability to work independently, and communicate effectively with patients, physicians, staff, and providers telephonically.
  • Balances business needs with patient advocacy.
  • Ability to work in a variety of settings with culturally diverse families and communities with the ability to be culturally sensitive and appropriate

Timeline

Registered Nurse UM Consultant

CVS Health
01.2018 - Current

Registered Nurse-Care Coordinator

Wellstar AMC
06.2016 - 11.2018

Registered Nurse- Care Coordinator

Northside Hospital
01.2015 - 01.2016

Registered Nurse – Case Management

Grady Health System
01.2008 - 01.2014

Registered Nurse - ICU

Grady Health System
01.2003 - 01.2008

Associate’s Degree - Nursing

Olive Harvey College

Bachelor of Science Degree - Biology

Rust College

Master's Degree in Public Administration - Focus in Health Services

Keller School of Management

Associate of Science - Nursing

Olive Harvey College
Renee Gibbs