Sheila G

Utilization Management RN / Assignment / Status Coordinator

Hospital • Part-time

Feb 2010 - Present • 16 yrs 7 mos

Saint Agnes Medical Center At Saint Agnes Medical Center, built a 15+ year career spanning critical care nursing and utilization management. From 2010 to 2019, served as Medical/Surgical ICU RN, Relief Crisis RN, and Relief Practice Coordinator in a 27-bed ICU across three specialized units, delivering advanced care for critically ill patients and managing complex conditions and life-support interventions. As Charge Nurse, oversaw daily operations, staffing, and patient flow, and responded to Rapid Response Teams and Code Blues with immediate critical interventions. Skilled in difficult and ultrasound-guided IV insertions, central line and Mediport management, titration of vasopressors, sedatives, inotropes, and blood products, CRRT, and advanced hemodynamic monitoring. Served as preceptor and resource nurse for new RNs and nursing students, coordinating patient/family education and multidisciplinary care conferences, while mentoring 30+ new ICU nurses and students, maintaining zero medication errors across 14 years of practice, contributing to a 25% reduction in Code Blue mortality, and ensuring optimal resource utilization and patient safety as Charge Nurse. In 2019, transitioned into a remote Utilization Management and ED Assignment Coordinator RN role at the same institution, held to present, conducting utilization reviews using InterQual® and MCG® criteria to ensure medical necessity and CMS compliance, performing preadmission and concurrent reviews across payers, validating Level of Care assignments, and collaborating with physician advisors on second-level reviews while resolving barriers to timely discharge. In this role, reduced avoidable days by 15%, achieved 98% compliance with CMS and payer audit standards, improved authorization turnaround time by 20%, managed $2M+ in annual inpatient claims while minimizing denials, and consistently ranked as top reviewer for quality and volume.

Utilization Management RN / Lead / Hybrid

Children's Health • Part-time

Jul 2022 - Jun 2026 • 3 yrs 11 mos

Valley Children's Hospital, Madera California, USA Conducts comprehensive utilization reviews using InterQual® and MCG® criteria to ensure medical necessity and compliance with CMS guidelines, performing preadmission and concurrent reviews across all payers and admissions while documenting outcomes in UM/Case Management software. Validates Level of Care assignments against government, payer, and accrediting body standards, and collaborates with physician advisors on second-level reviews for cases not meeting initial screening criteria, proactively identifying and resolving utilization barriers that impact timely discharge and care transitions. Through proactive discharge planning and early intervention, reduced avoidable days by 15% while achieving 98% compliance with CMS and payer audit standards for medical necessity documentation; improved authorization turnaround time by 20%, enhancing patient flow and reducing delays, and successfully managed over $2M in annual inpatient claims, minimizing denials and optimizing reimbursement. Recognized as top reviewer for quality and volume of utilization reviews, consistently exceeding departmental benchmarks throughout tenure.