Cassidy R Balensiefen

Post Acute Utilization Clinical Review Nurse

CareCentrix

Aug 2023 - Feb 2026 (2 years 7 months)

Initially hired for reviewing Home Health Review, advanced to Post Acute Care Review for Medicare, Medicaid, Commercial, WellCare, Ambetter, Excellus, Univera. Established scheduled telephonic touch points with facility points of contact to review members' status and confirm appropriateness for continued stay. Authorized continued stays at SNF, IRF, LTACH, and Home Health care using approved medical guidelines and collaborated with facility personnel. Ensured case review and determination within contractual and regulatory turnaround times. Interacted with the PAC Medical Director to ensure accurate medical necessity decisions and assisted in care planning, goal setting, and reviewing discharge plans for optimal outcomes. Provided clinical e

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Associate Clinical Review Nurse

New Century Health

Jan 2023 - Jul 2023 (7 months)

Reviewed cardiology authorizations requests for medical necessity and obtained sufficient medical documentation for informed consent. Processed authorization information for Molina Medicaid, Medicare, and Market Place of IL, OH, MI, KY, NV, and WA ensuring case review and determination within contractual and regulatory turnaround times. Maintained detailed, compliant documentation of all authorization review steps in the authorization system. Utilized CMS and Health Plan Hierarchy criteria. Referred cases to the Medical Director for review of requests that may not meet medical necessity criteria. Processed denials within established timeframes and wrote denial letters to meet CMS and Health Plan requirements.

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Utilization Review Nurse

MEDIXEvolent

Jul 2022 - Jan 2023 (7 months)

Reviewed authorization radiology requests including MRI's and CT's for Medicaid, Medicare and Market Place plans for IL, OH, MI, NY; for medical necessity. Referred cases to the Medical Director for review of requests that may not meet medical necessity criteria. Consulted with the medical director on cases that do not meet the established guidelines. Reviewed and utilized clinical criteria, including but not limited to, InterQual, Milliman Care Guidelines ("MCG”), CMS, Medicare Policies, and State Specific Clinical Criteria. Followed up and processed denials within established timeframes and wrote denial letters to meet CMS and Health Plan requirements.

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Prior Authorization Clinical Review Clinician - LPN

The MAXIS GroupMolina

Mar 2022 - Jul 2022 (5 months)

Evaluated outpatient authorization requests for medical necessity across multiple state Medicaid and Marketplace plans, including Wisconsin, Illinois, and Ohio. Reviewed and utilized clinical criteria, including but not limited to, InterQual, Milliman Care Guidelines ("MCG”), QNXT, Propat, Medicare Policies, and State Specific Clinical Criteria. Conducted pre-authorization referral reviews, following workflow, documenting criteria to make determination or recommendation and processed the referral in a timely manner.

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Utilization Review Nurse

Total Med SolutionsAetnaCV

Feb 2021 - Mar 2022 (1 year 2 months)

QNXT, Pro Pat, Mcg. Conducts pre-authorization referral reviews for DME, Surgical Procedures, lab testing, PT/OT/ST, for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed consent. Consults with the medical director on cases that do not meet the established medical necessity. Follows up and processes denials within established timeframes. Applied evidence-based clinical criteria, including InterQual, Milliman Care Guidelines (MCG), Medicare policies, and state-specific clinical criteria, to support medical necessity determinations.

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MDS Coordinator

Regency Healthcare

Jan 2020 - Feb 2021 (1 year 2 months)

Conducts comprehensive assessments of residents to determine their medical, psychological, and social needs using the Minimum Data Set (MDS). Collaborates with interdisciplinary teams to develop individualized care plans based on MDS assessments, ensuring they address the specific needs and preferences of each resident. Ensures that all MDS documentation and processes comply with federal and state regulations, staying updated on changes to maintain compliance. Oversees the collection and analysis of patient data, ensuring accurate completion of the MDS to reflect the clinical status of each resident. Works closely with nursing staff and other healthcare professionals to coordinate quality care and monitor patient health. Analyzes data to id

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LPN/Behavioral Health Clinical Nurse

PERRY MEMORIAL HOSPITAL

Sep 2018 - Oct 2019 (1 year 2 months)

Works side by side scheduling and triaging urgent calls for tele-psychiatrist. Takes calls for possible appointments, medication refills, urgent care, help with all patient needs. Gives Injections, vaccinations. Provides patient education and works as an advocate for patients. Assessments and proper documentation using EMR.

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Surgical Consultation Nurse

ASSOCIATED ORAL SURGEONS

Sep 2017 - Aug 2018 (1 year)

Conducted pre-surgical health screenings to ensure patient readiness for procedures and determined if additional in-patient consultation was needed. Provided patient education regarding surgical procedures, anesthesia, and post-operative care. Acted as a resource point of contact for maxillofacial patients and their families. Coordinated scheduling for surgical consultations and procedures. Tracked and managed procedural scheduling completed via phone consultations.

Respiratory Technician/LPN

OSF HealthCare

Aug 2016 - Sep 2017 (1 year 2 months)

Administered prescribed respiratory therapy treatments under the direction of a respiratory therapist, including chest physiotherapy (CPT), IPV, and oscillatory vest therapy. Provided emergency support care, including artificial respiration, CPR, and assistance with cardiopulmonary resuscitation. Documented respiratory treatments and patient responses accurately in the medical record. Educated patients and families on respiratory treatments and preventive care measures. Trained and oriented new staff members within the department.

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Facility Director & LPN

Bradford Courtyard Estates

Jul 2015 - Sep 2016 (1 year 3 months)

Responsible for managing, planning, organizing, staffing, directing, reporting, budgeting and physical management of the facility, residents and equipment in accordance with state and federal regulations. Daily assessment of tenants experiencing change of condition. Oversees medication management program. Plans tenant services. Completes written assessment process and creates service plans based on assessment. Oversees nursing employees, assigning and directing nursing personnel. Manages staff education by planning in-service to improve knowledge and skills. Manages resident/tenant education. Directs incidents and abuse investigations. Manages Grievances/Complaints. Served as Committee Chairperson for: Quality Improvement Committee. Reviews

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LPN

St. Josephs Nursing Home

Apr 2015 - Jul 2015 (4 months)

Provided basic nursing care including monitored respiration, blood pressure, temperature, oxygen levels and heart rates residents. Provided wound care, gave injections, administered medications. Charted, followed physician order for proper resident care.

LPN Primary to OBGYN

CGH

Sep 2014 - Apr 2015 (8 months)

Billing, Coding, Insurance Precertification, Referrals. Calls in prescriptions, Indirect Patient Care through phone calls. Direct Patient care, Vitals, Health Assessments, Injections, Charting. Procedure set up, assists during procedures, provides patient education.

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Home Health Aide

Henry County Health Department

Jan 2014 - Sep 2014 (9 months)

Helped with basic home care, provided meals, helped with laundry and cleaning. Helped with grocery shopping and getting clients to doctor's appointments. Bathed, fed, took vitals, assisted with medications.

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CNA

Liberty Village

Jul 2013 - Jan 2014 (7 months)

Took vitals, bathed, provided basic care and help with ADL's. Assisted with resident's daily routine. Accompanied residents on outings.

Cassidy R Balensiefen

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