Caroline Buczik
wilmington
Summary
Dynamic Concurrent Review Nurse with a proven track record at AmeriHealth Caritas, excelling in medical necessity reviews and patient advocacy. Expert in interdisciplinary collaboration and effective communication, successfully implementing processes that enhanced in-patient care quality. Committed to optimizing case management strategies for high-risk populations, ensuring continuity of care and improved patient outcomes.
Customer-focused individual with a passion for delivering exceptional service. Strong interpersonal skills with a talent for effectively addressing concerns. Committed to improving customer satisfaction and driving positive outcomes.
Overview
17
17
years of professional experience
Work History
Concurrent Review Nurse
AmeriHealth Caritas
Newark
12.2017 - 04.2025
- Conducted initial reviews of medical records to determine appropriateness of requested services.
- Interpreted clinical data from medical records and applied evidence-based criteria in order to make decisions regarding the appropriateness of care provided.
- Performed concurrent review activities to ensure that treatments are medically necessary and meet quality standards.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Communicated effectively with payers, providers, and members regarding authorization status and service denials.
- 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.
- Precepted new nurses and staff and provided continuous hands-on development opportunities.
- Advised physicians on appropriate documentation required for appropriate reimbursement under various payer sources.
- Assessed patients' eligibility for coverage according to insurance guidelines.
- Coordinated discharge planning to ensure continuity of care post-hospitalization.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Developed strategies for improving case management processes including managing high risk populations.
- Referred patients to specialized health resources or community agencies to furnish additional assistance.
- Utilized knowledge of the principles of managed care organizations while performing concurrent review activities.
Clinical Appeals Coordination/UM Concurrent Reviewer
Coventry Health Care/ Aetna
Wilmington
11.2010 - 03.2017
- Assessed the need for continued stay by reviewing clinical documentation in order to determine if the admission or continued stay is medically necessary.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Assessed the appropriateness of medical services and procedures based on clinical documentation and criteria.
- Identified opportunities for cost savings through utilization management techniques such as discharge planning, case management, and alternate level of care.
- Provided feedback to healthcare providers on clinical documentation improvement to support utilization review.
- Collaborated with staff members in group meetings to identify issues and find cost-effective solutions.
- Performed retrospective reviews on high cost cases identified by payers or other sources as potentially inappropriate use of resources.
- Participated in multidisciplinary team meetings to discuss patient care issues and utilization review findings.
- Conducted medical necessity reviews and concurrent reviews of inpatient, outpatient, and home health services to ensure compliance with applicable standards and regulations.
- Collaborated with case managers to facilitate timely discharge planning and transition of care.
Dialysis Registered Nurse
Fresenius Medical Services
Wilmington
08.2009 - 10.2010
- Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
- Managed time efficiently by prioritizing workloads according to urgency.
- Monitored patients' responses to dialysis treatment and reported any changes or adverse reactions to the physician.
- Assessed patient needs before starting hemodialysis procedure and monitored vital signs throughout treatment process.
- Supervised dialysis treatments for patients aging from child to adult in community hospital setting.
- Administered oral, IV and intra-muscular medications and monitored patient reactions.
- Provided emotional support for patients who are struggling with their diagnosis.
- Prepared medical equipment and tools to aid physician during examination and treatment of patients.
- Updated medical records with current vitals, behavioral observations and medication details.
Registered Nurse
Beebe Medical Center
Lewes
03.2008 - 08.2009
- Demonstrated excellent interpersonal communication skills when interacting with patients, family members, physicians or other healthcare professionals.
- Conducted specified laboratory tests to help detect conditions and determine diagnosis.
- Administered medications and treatments as directed and as appropriate for patient's medical care in collaboration with multi-disciplinary team.
- Instructed patients and families in health promotion activities such as proper nutrition, wound care and disease prevention.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Incorporated cultural diversity into all aspects of patient assessment and management strategies.
- Administered oral, IV and intra-muscular medications and monitored patient reactions.
- Observed strict safety measures, including checking medication dosages before administration to patients.
- Prioritized workloads according to urgency levels ensuring timely completion of assignments.
- Responded quickly and effectively to life threatening situations utilizing advanced cardiac life support protocols.
Education
Associate of Applied Science - Nursing
Delaware Technical And Community College
Georgetown DE02-2008
Associate of Arts - Business Management
Delaware Technical Community College
DE09-1985
Skills
- Medical necessity review
- Clinical documentation improvement
- Case management
- Utilization management
- Patient advocacy
- Interdisciplinary collaboration
- Discharge planning
- Effective communication
- CPR/AED
- Care coordination
Affiliations
- Volunteer with community organizations, Boy Scouts and School activities.
- Active traveler who has been to 40 countries and over 35 states.
Accomplishments
- Received 2 presidential accolades while at Beebe from patient letters written about my performance and compassion.
- Started at Coventry as an appeals nurse and received a $500 award for restructuring the position and saving the company over $50,000 my first 6 months.
- When I transitioned from appeals to concurrent review, I was asked to create a note book on the appeal process that was used for all subsequent appeals coordinators.
- At AmeriHealth Caritas, I trained multiple new hires on the position as well as performing supervisor role of conducting case management rounds for the first 4 years. I was also asked to audit InterQual reviews from other review nurses to make sure proper diagnosis and criteria used for compliance.
Timeline
Concurrent Review Nurse
AmeriHealth Caritas
12.2017 - 04.2025
Clinical Appeals Coordination/UM Concurrent Reviewer
Coventry Health Care/ Aetna
11.2010 - 03.2017
Dialysis Registered Nurse
Fresenius Medical Services
08.2009 - 10.2010
Registered Nurse
Beebe Medical Center
03.2008 - 08.2009
Associate of Applied Science - Nursing
Delaware Technical And Community College
Associate of Arts - Business Management
Delaware Technical Community College
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