Nicole Scott

Registered Nurse (RN) with 10+ years of experience in Utilization Reviw, Case Management, Condition Management, and Prior Authorization within managed care and insurance settings. Strong background in medical necessity determination, evidence-based clinical review, and  Strong background in medical necessity determination, evidence-based clinical review, and regulatory compliance. Experienced in reviewing inpatient, outpatient, and specialty services using MCG (Milliman Care Guidelines) and InterQual criteria. Proven ability to collaborate with providers, interdisciplinary teams, and members to improve quality outcomes and cost-effective care. Experienced working independentl/remotely for 10 yrs at my previous job. Also my history of pediatric intensive care and pediatric clinic care nursing which gives me a diverse background to better understand patients and families needs. Thank you for your time and consideration. 

Registered Nurse - Utilization Review / Case Manager /

Condition Management

2013 - 2023

• Performed utilization review for inpatient, outpatient, and specialty services to determine medical necessity and appropriate level of care.
• Applied MCG and InterQual criteria to ensure compliance with evidence-based guidelines and payer policies.
• Reviewed clinical documentation to support prior authorization decisions and reduce denials.
• Managed complex and high-risk cases to improve quality outcomes and cost containment.
• Coordinated care transitions, discharge planning, and post-acute services.
• Collaborated with physicians and providers to obtain additional clinical information and support authorization approvals.
• Participated in quality assurance and policy review initiatives.
• Selected for enterprise-level COVID-19 care coordination project in collaboration with executive leadership.

AIM Specialty Health (American Imaging Management) - Westchester, IL

Registered Nurse - Clinical Review

2012 - 2013

• Conducted prior authorization and utilization review for advanced imaging services.
• Evaluated clinical documentation to determine medical necessity.
• Ensured compliance with national imaging guidelines and payer requirements.
• Communicated determinations and clinical rationale to ordering providers.

Advocate Hope Children's Hospital - Oak Lawn, IL

Registered Nurse - Pediatric Intensive Care Unit (PICU)

2010 - 2012

• Delivered high-acuity pediatric critical care including ventilator management and hemodynamic monitoring.
• Administered medications, managed life-support equipment, and responded to emergencies.
• Educated and supported families during complex medical situations.

Saint Xavier University - Chicago, Bachelor of Science in Nursing (BSN),

2008

Certifications

• Registered Nurse - State of Illinois
• CPR/BLS Certification

Core Competencies

• Utilization Review & Medical
  Necessity Determination
• Case Management & Care
  Coordination
• Prior Authorization & Clinical
  Review
• InterQual / MCG Guidelines
• Healthcare Policy & Compliance
• Member & Provider Collaboration
• Quality Improvement Initiatives
• Data & Policy Analysis
• Electronic Documentation Systems
• Microsoft Office (Word, Excel)