Troy, Michigan, United States
Registered Nurse and healthcare operations leader with more than 25 years of experience across critical care, clinical review, and Medicare Advantage clinical decision support. I have built a career focused on improving patient outcomes while ensuring healthcare organizations maintain the highest standards of quality, compliance, and operational performance. Currently serving in a leadership role supporting Medicare Advantage clinical decision support, I bring deep expertise in utilization management, medical necessity determinations, regulatory compliance, and quality improvement initiatives. I have extensive experience working within regulatory frameworks while collaborating with physicians, care teams, and operational leadership to ensure appropriate levels of care and efficient service delivery. Throughout my career, I have successfully led clinical teams, developed training programs, and coached healthcare professionals to strengthen performance and improve workflow efficiency. My leadership approach focuses on mentorship, accountability, and continuous improvement while maintaining a strong commitment to patient-centered care. My background also includes extensive critical care experience, organ donation coordination, and hospital leadership roles, providing me with a comprehensive understanding of healthcare from bedside care to system-level operations. This combination of clinical expertise and operational leadership allows me to bridge the gap between clinical practice, regulatory requirements, and organizational performance. Key areas of expertise include: • Clinical Operations & Healthcare Leadership • Medicare Advantage & Utilization Management • Regulatory Compliance • Medical Necessity & Prior Authorization Review • Quality Improvement & Performance Metrics • Staff Development, Coaching & Training • Chart Review, EMR Analysis & Clinical Auditing • Cross-Functional Healthcare Collaboration I am passionate about strengthening healthcare systems, supporting high-performing teams, and ensuring patients receive the highest quality care possible.
In my current leadership role, I oversee clinical decision support operations for Medicare Advantage members, ensuring medical necessity determinations and prior authorization reviews align with evidence-based guidelines and regulatory standards. I lead multidisciplinary teams responsible for utilization management, precertification reviews, and clinical case processing while maintaining compliance with CMS and NCQA requirements. My role focuses on operational leadership, staff development, and continuous improvement across clinical review workflows. Key responsibilities include: • Leading daily operations for clinical review teams responsible for medical necessity and prior authorization decisions • Monitoring productivity, quality metrics, and turnaround times to ensure operational efficiency and regulatory compliance • Coaching and mentoring clinical and non-clinical staff while supporting professional development and accountability • Collaborating with physicians, operational leaders, and cross-functional departments to support member care and service delivery • Identifying process improvement opportunities to streamline workflows and reduce administrative burden
As Team Leader, I supervised a team of clinical reviewers responsible for utilization management and medical necessity determinations for Medicare Advantage members. I managed day-to-day operations including staffing, workflow management, and quality oversight while ensuring compliance with CMS, NCQA, and internal clinical guidelines. Key contributions included: • Supervising and developing a team of 7–14 clinical staff members responsible for case review and clinical decision support • Conducting performance evaluations, coaching, and professional development planning • Serving as a subject matter expert for utilization management, clinical criteria review, and appeals processing • Leading hiring, onboarding, and training initiatives for new team members and contractors • Preparing operational reports and quality metrics for leadership
In this role, I conducted comprehensive clinical reviews of inpatient services to evaluate medical necessity, appropriate level of care, and length of stay for Medicare Advantage members. Responsibilities included: • Performing prospective, concurrent, and retrospective utilization reviews using provider EMR systems • Reviewing medical records and clinical documentation to ensure compliance with established guidelines • Investigating appeals and retrospective review requests while maintaining regulatory compliance • Collaborating with physicians, case managers, and interdisciplinary teams to recommend alternative treatment plans and service levels.
Took time away from full-time clinical work to focus on raising my family while maintaining my nursing license and staying engaged with healthcare developments and professional education.