Utilization Management Resume Samples

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H McClure

Hilton

McClure

444 Rogahn Court

Houston

+1 (555) 378 3055

444 Rogahn Court

Houston

Phone

p +1 (555) 378 3055

Experience Experience

Los Angeles, CA

Manager of Utilization Management

Los Angeles, CA

Renner-Bogisich

Los Angeles, CA

Manager of Utilization Management

Monitors, evaluates and provides ongoing feedback to staff, in a timely manner, regarding work performance, incorporating performance improvement goals
Oversee the Utilization Management Committee and ensure adequate representation for UM on all work teams and committees
Develop, recommend and manage department budget
Administers quality standards that have been established for all Utilization Management, Care Coordination and support staff
Oversight of clinical rounds both internally and with health plans and providers for the purpose of utilization management
Direct the development, implementation, and updating the approval process for the Utilization Management Plan
Provide innovation and input to improve member care, operational efficiency, and regulatory compliance

New York, NY

Manager, Utilization Management Required

New York, NY

VonRueden, Mante and Cummings

New York, NY

Manager, Utilization Management Required

Provide weekly updates to Director of Utilization Management
Develop relationship and acting as back-up liaison with payers, providers and facilities regarding UM policies and procedures
Monitor caseloads/workload and performance
Assist and monitor referral and triage process and review all emergent cases with Director of UM and CHIPA Physician Advisor
Assist with reviewing and updating UM policies and procedure
Participate in provider and plan meetings as assigned
Assist/monitor consistency amongst UM staff in application of Level of Care Criteria

present

Chicago, IL

Director of Utilization Management

Chicago, IL

Fahey-Nienow

present

Chicago, IL

Director of Utilization Management

present

Participate in creating, developing, updating, and maintaining department policies and procedures
Attends Morning Meeting on a daily basis. Provides critical information
Develop and adhere to department budget including growth planning
Implement management processes according to organization and department policies and procedures
Works with the Medical Directors with decision making of medical necessity cases, specialists, and primary care physicians
Assists nurses in developing contacts and relationships with providers, provider’s office staff and ancillary facilities personnel
Assists nurses in developing contacts and relationships with payers and other clients

Education Education

Bachelor’s Degree in Related Field

University of Arizona

Bachelor’s Degree in Related Field

Skills Skills

Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines
Analyzes clinical service requests from members or providers against evidence based clinical guidelines
Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures
Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner
Requests additional information from members or providers in consistent and efficient manner
Makes appropriate referrals to other clinical programs
Collaborates with multidisciplinary teams to promote Molina Care Model
Adheres to UM policies and procedures
Oral and written communication, Critical thinking, Organization and time management, and Customer service
Current unrestricted Registered Nurse licensure in the State of Texas

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Utilization Management Case Manager Resume Examples & Samples

5+ years of related experience with 3+ years of experience in an Adult, Acute Care setting (Medical-Surgical, Emergency Room, Critical Care, etc.)
Experience in Managed Care organization
Experience in Home Health, Community Health/Outreach or acute care UR/Discharge Planning

Director of Utilization Management Resume Examples & Samples

BSN and/or Degree in Business or Healthcare Management
Strong Utilization Management experience
Knowledge of the Health Care Delivery system
Management background
Knowledge of current Care / Case / Disease Management methodologies and Program Development
Broad clinical knowledge

Utilization Management Reviewer, Junior Resume Examples & Samples

Work closely with Behavioral Health Clinical Manager to develop and implement a utilization management program for the Wyoming State Hospital
Complete utilization reviews for continuing stay, based on medical necessity criteria within timeline
Assess and recognizes benefit value to cost and acts upon cases to affect savings while maintaining quality care
Complete reports to capture utilization patterns, barriers to discharge, and make system of care recommendations
Attend various clinical treatment team meetings on-site at the State Hospital
Work closely with facility, family/guardian, and community providers to ensure successful discharge of state hospital patients
Maintains knowledge of cultural differences including socioeconomic factors, cultural traditions and spiritual beliefs, and researches these differences as needed via libraries, Internet and/or professional journals
Maintains current knowledge of Federal, State, and local funding along with community resources available
Experience with the serious, persistently mentally ill population preferred

Senior Director of Utilization Management Resume Examples & Samples

Bachelor's Degree in Nursing and/or Business or Healthcare Management
Knowledge of current Care / Case / Disease Management methodologies and Program development
Solid management background
Knowledge of the Healthcare Delivery System

Utilization Management Case Manager Resume Examples & Samples

Knowledge of medical terminology, ICD-9 and CPT coding
Excellent communication skills and interpersonal skills
2 years of managed care experience

Utilization Management Case Manager Resume Examples & Samples

2+ years of prior Utilization Management experience (Admissions, Utilization Review, and/or Discharge Planning)
Strong knowledge of Medicaid / Medicaid programs
Working knowledge of Interqual
Solid clinical and assessment skills

Utilization Management Rep Resume Examples & Samples

1 year of customer service or call-center experience; proficient analytical, written and oral communication skills; or any combination of education and experience, which would provide an equivalent background
Medical terminology training and experience in medical or insurance field preferred
ECC and WMDS experience preferred

Director, Utilization Management Resume Examples & Samples

Oversee the operations of the referral management, telephonic utilization review, prior authorization, and case management functions
Support and perform case management, disease management and on-site concurrent review functions as necessary
Provide support to Provider Relations issues related to Utilization issues for hospitals and physician providers

Manager, Utilization Management Resume Examples & Samples

Review analyses of activities, costs, operations and forecast data to determine progress toward stated goals and objectives
Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions
Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure
Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management
Facilitate on-going communication between utilization management staff and contracted providers

Director, Utilization Management Resume Examples & Samples

Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations
Optimizes processes and workflows to achieve successful quality outcomes and benefit maximization within the scope of responsibility
Possesses the flexibility to act as a subject matter expert liaison for Clinical Services and/or a leader on cross-functional teams
Formulates strategic solutions to enhance quality outcomes
Executes periodic competitor utilization management program comparison and analysis to ensure WellCare’s utilization management program maintains competitive edge
Provides leadership and support to front-line staff, supervisors and managers
Promotes and improves environment of Provider and Health Plan partnership
Ensures monitoring and tracking tools are in place to adequately link and assess production and quality driven work products and outcomes to individual performers
Develops formal policies, procedures and workflows that effectively guide work activity
Develops formal department-specific new employee orientation and training programs
Chairing monthly UM meetings
Required A Bachelor's Degree in Nursing (BSN)
Preferred A Master's Degree in Business, Public Health or Healthcare administration
Required 7+ years of experience in acute clinical/surgical experience and/or behavioral health clinical setting
Required 3+ years of management experience in a managed health care setting
Required Other current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
Ability to work within tight timeframes and meet strict deadlines
Ability to lead/manage others
Ability to work in a fast paced environment with changing priorities
Demonstrated written communication skills
Ability to create, review and interpret treatment plans
Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Demonstrate effective critical thinking and decision making skills
Ability to communicate on any level required to meet the demands of the position
Ability to correctly write business letters and comprehensive reports
Preferred Other Utilization review/management certification, or equivalent professional certification
Required Intermediate Microsoft Word Ability to use proprietary health care management system

Director, Utilization Management Resume Examples & Samples

Required A Bachelor's Degree in Nursing (BSN), Health Administration, Nutrition or business related field
Intermediate Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
Intermediate Ability to work within tight timeframes and meet strict deadlines
Intermediate Ability to create, review and interpret treatment plans
Intermediate Other Demonstrate effective critical thinking and decision making skills
Intermediate Other Ability to communicate on any level required to meet the demands of the position
Intermediate Other Ability to correctly write business letters and comprehensive reports

Director, Utilization Management Resume Examples & Samples

Bachelor's Degree in Nursing (BSN) or equivalent work experience is required
Master's Degree in Nursing is preferred
7+ years of experience in acute clinical/surgical experience and/or behavioral health clinical setting is required
3+ years of management experience in a managed health care setting is required
Current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews is required
Licensed Registered Nurse (RN) is required
Utilization review/management certification, or equivalent professional certification is preferred
Intermediate Microsoft applications, including Word, Excel, PowerPoint and Outlook is required

VP, Utilization Management Resume Examples & Samples

Coordinates the Medical Management Committee’s activities and interactions with applicable company and UM. Acts as a resource for problem solving with all departments
Responsible for identification of UM function needs and for the preparation of a program including staff duties designed to meet the needs of the company; this involves constant evaluation of the program with recommendations for revision as indicated
Responsible for implementing a UM management program that is structured to meet the needs of the patients and is not overly burdensome for the PCP’s to manage
The solicitation of this program to customers must provide a mission for retention of members as well as advocate improvements to market future members with a goal of securing future success of the company
Manages staffing ratios of all personnel, the assignment of duties, the supervision of the effectiveness of the UM program related to staff, within the structure of the budget for the department
Ensures staff has access to necessary training relevant to their duties to maximize operational efficiency using all resources available
Motivates employees; key to effectiveness of the Vice President is the ability to motivate and work with staff
Responsible for maintaining a continuum in policy that meets national standards and health plan guidelines guaranteeing the effectiveness and success of the UM Program
Accountable for disseminating information to the Medical Management Committee regarding UM function and activities of the department
Collaborates with leadership team for planning, development, and implementing business projects for overall success of the company
Submits a written quarterly analysis of UM activities to the Medical Management Committee and all clients. The information should include effectiveness of UM program and staff, and if indicated, a plan of action to meet UM goals
Oversees and ensures that WellMed UM Department adheres to all regulations and contractual agreements. Provides in-services on compliance to better prepare WellMed clinics for audits
Responsible for planning the UM budget and all expenditures within the framework of the company budget; this responsibility includes the management of salaries, operating expenses, and UM assets used for daily operations
Participates in the budgeting process by informing the CMO of capital and operating needs
Performs other duties at the request of the department head
Bachelor of Science in Nursing (BSN) (8 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
Active and unrestricted Registered Nurse, licensed in Texas
8+ years of management-level utilization management experience in managed care with HMO health plans
Progressive experience working with contract language, claims, UM management guidelines and accreditation guidelines
Demonstrates strong organizational and time management skills
Ability to delegate assignments with diplomacy
Strong interpersonal skills with the ability to interact with professional and non-professional staff utilizing effective verbal and written communication skills
Ability to solve problems and coordinate multiple activities
Must possess sound knowledge of managed care, NCQA and federal regulations
Working knowledge of referral processes, claims, case management, contracting and physician practices

Manager Utilization Management Resume Examples & Samples

Oversees the Inpatient case management area
Manage a team size of approximately 15 - 20 nurses
Responsible for metrics of team and productivity reporting
Responsible for auditing of nurses to monitor that clinical criteria guidelines are being followed
Daily/weekly multidisciplinary case rounds
Required to created innovative approaches to meeting metrics
Responsible for participating in workgroups and initiatives
Support and drives change management for all initiative
Responsible for auditing and staff development, training, performance management and all hiring/ onboarding processes
Troubleshoot and investigate claims and authorization issues as needed
Participation in Regional/national committee meetings
Occasional local/national travel
Work queues management
Daily census management
Registered Nurse (RN), current and unrestricted license
Experienced with medical necessity guidelines including MCG guidelines and/or InterQual guidelines
Experienced in Medicaid, Medicare and/or Commercial lines of business
Understanding utilization review process including census management
3 or more years of acute med/surge experience post licensure
Intermediate computer skills to include Microsoft Office, email, Internet and clinical programs
MCG Certification
3 or more years supervisory/leadership experience
3 or more years of Managed Care experience

Manager, Utilization Management Resume Examples & Samples

Conducts utilization data analysis (avoidable days, readmissions, UMAB, PRS reports, one-day stays, DRGs, LOS, PDRs, etc.) for trending and development of performance improvement initiatives. Partners with the UM Chief and KFH/TPMG local medical center leadership, to engage the following areas in the development and implementation of a comprehensive utilization management work plan to meet or exceed medical center targets: Physicians, managers across the continuum, and TPMG/KFH service leaders and managers. May include oversight of the coordination of KP members' care with leaders responsible for UM activities associated with alliance/contract hospitals and networks
Collaborates with interdisciplinary teams across the continuum of care including, but not limited to (HBS, TPMG Sub-specialty departments, Nursing, MSW, PT/OT, HH, Hospice, SNF, CCM, Behavioral Health, Rehabilitation, etc.). to ensure patient care is effectively provided, clinically appropriate, service oriented, safe and cost effective. Partners with TPMG to provide UM related education and training as needed
Manages department budget and finances. Develops implements, and monitors departmental policies and procedures
Minimum three (3) years of previous experience in utilization management activities required

Director Utilization Management Resume Examples & Samples

Provides overall direction, design, development implementation and monitoring of utilization programs to meet the Service Area's or Medical Center's utilization goals while maintaining customer satisfaction
Acts as a resource to the medical staff, administrative staff, divisional, SCPMG, TPMG and external regulatory agencies in all issues relating to utilization management within the Service Area or Medical Center
Analyzes and reports significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees
May direct the operations of outside referrals/transportation services
May serve as contract liaison for the Service Area or Medical Center on issues pertaining to new or existing contracts with outside vendors
Develops, monitors and controls department's budgets
Hires, coaches, trains and disciplines staff to ensure smooth operations in utilization management
Also facilitates educational training for medical staff on issues related to utilization management
Master's degree in a related field such as nursing, business or health services administration preferred
CCM Preferred

Director Utilization Management Resume Examples & Samples

Day to Day Operations: Directs the day-to-day operations for Regional Utilization Management, case coordination, discharge planning. Plans, supervises, and evaluates work assignments. Ensures timeliness and appropriateness of review of cases. Directs and coordinates team efforts to optimize hospital days. Participates in utilization rounds for timely, appropriate medical treatment. Evaluates plan of care. Communicates discharges to Bed Control in tight bed situations. Manages patient complaints related to UM or discharge planning. Oversees denials, termination of benefits, and appeals processes. Directs programs that optimize patient/family and/or member satisfaction with care received in the KP and non-Kaiser facilities setting. Develops strategies for determining the most cost-effective, efficient levels of continuing patient care. Provides clinical leadership and support to patient care team
Department Performance Excellence: Directs the quality and performance criteria, policies and procedures, and service standards for the utilization management operations. Leads, contributes, and provides technical leadership to highly visible, large, complex multi-dimensional analytical and clinical projects that identify and resolve utilization management issues of strategic importance to the Hawaii Region. Evaluates utilization reviews and determines program improvements. Implements modifications and improvements to existing programs as needed. Designs research plans for data gathering and analysis. Participates in interpreting analysis and developing action plans accordingly. Determines goals and priorities with management team sponsors. Ensure that action plans integrate well across other departments in the continuum of care
Authorizations and Referrals Management:Provide management and supervision of the Authorization and Referrals Management. Ensure that referrals are processed accurately and timely. Ensure that referral guidelines are up to date and processed accurately and timely. Develops, coaches and manages a staff dedicated to providing high quality clinical care/service. Determines the appropriate staffing requirements and develops processes to interview, hire, train and maintain the department staff. Assesses professional development needs of staff and plans for training/continuing education of professional staff
This job description is not all encompassing
Minimum eight (8) years of experience in a clinical environment to include outpatient, acute, or post-acute care
Master's Degree in health care administration, public administration, nursing, health services or business administration, or related field
Knowledge of Home Health, Palliative Care Hospice and SNF programs

VP-utilization Management Resume Examples & Samples

MD or RN license
5+ years of utilization management experience in a health plan
Team leadership roles
Ability to work closely with related teams and leaders
Strong interpersonal, verbal, and written communication skills
Ability to build and manage the utilization management function in our fast-moving environment
Experience doing utilization reviews and leading utilization management teams
Ability to create and teach utilization management guidelines
Understand how to create and refine processes

VP, Utilization Management Resume Examples & Samples

Responsible for the development, implementation and application of clinical strategy as it relates to Utilization Management (along with the Chief Medical Director)
Coordinates the development, implementation and application of policies and procedures for utilization management in partnership with the Chief Medical Director. Interacts with Corporate, and other local market health plan Medical Directors and Health Services management as needed
Responsible for overall inpatient and outpatient UM outcomes, including the location of work teams (both centralized and decentralized teams). Directs the development and establishment of business process improvement activities to optimize performance
Advises committees on current standards and requirements for their respective programs
Maintains a working knowledge of legislative changes that may potentially affect utilization trends, practices, and standards. Ensures that compliance and regulatory standards are met with regard to department policies and procedures
Ensures adherence for accreditation (NCAQ, URAC, other) activities within the Enterprise
Serves as a resource both to department staff and those outside the department for information and consultation on issues relating to Utilization Management including consulting on the design of the new Medical Management platform
Ensures that pertinent, comprehensive, and accurate statistical information related to Plan activities is available and monitored
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions
Cultivates interdepartmental communication and cooperation to maximize service to members and providers and to assure a coordinated and comprehensive approach to problem solving and utilization management
Required A Bachelor's Degree in nursing
Preferred A Master's Degree in nursing or healthcare administration
Required 10+ years of experience in a health insurance environment with an emphasis in managed care programs
Required 7+ years of management experience preferably in a managed care environment
Required 5+ years of experience in Utilization Management
Advanced Ability to work within tight timeframes and meet strict deadlines Ability to work independently, handle multiple assignments and prioritize workload
Advanced Ability to create, review and interpret treatment plans Ability to create, review and interpret treatment plans
Advanced Demonstrated negotiation skills Demonstrates negotiation skills
Advanced Demonstrated time management and priority setting skills Demonstrates high level time management and priority setting
Advanced Demonstrated leadership skills Abilty to lead and manage others
Advanced Demonstrated written communication skills Strong oral and written communication skills
Advanced Ability to implement process improvements
Advanced Demonstrated organizational skills
Advanced Other Thorough knowledge of utilization review practices and standards for managed care delivery programs, ICD-10-CM and CPT coding, discharge planning, quality improvement and credentialing
Advanced Other Knowledge of information systems programs related to managed care
Required Other current state license
Required Intermediate Microsoft Excel Proficient in Microsoft Office such as Excel, PowerPoint, Word, Project and Outlook
Required Intermediate Microsoft Project

Utilization Management Rep-st Louis Resume Examples & Samples

Requires High school diploma/GED
2 years customer service experience in healthcare related setting and medical terminology training; coding, problem solving, and strong organization, written and oral skills; or any combination of education and experience, which would provide an equivalent background
Able to multitask and work independently
Excellent computer skills and typing skills are strongly preferred

Manager of Utilization Management Resume Examples & Samples

Collaborates with the multi-disciplinary teams to plan and coordinate care across the continuum
Manages transportation program to ensure appropriate utilization of resources which meet Health
Provides direction to staff regarding utilization review, care coordination, discharge planning, and other services across the continuum of care
Minimum three (3) years of experience in utilization management and discharge planning in an acute care setting to also include supervisory or management experience

Senior Dir, Utilization Management Resume Examples & Samples

Provides direction and oversight to ensure effective management of inpatient care, discharge planning, and prior authorizations for medical or behavioral health
Optimizes processes and work flows to achieve successful quality outcomes and benefit maximization within the scope of responsibility
Possesses the flexibility to act as a subject matter expert liaison for Health Services and/or a leader on cross-functional teams
Serves as an instrumental partner in development of key performance indicators. Monitors and tracks key performance indicators to independently identify over/under utilization patterns and/or deviation from expected results
Develops processes and procedures to ensure department-wide compliance with contractual, regulatory (Federal/State) and accreditation entities
Serves as the subject matter expert for inpatient and prior authorization management for future expansion and growth efforts
Develops formal policies, procedures and work flows that effectively guide work activity
Provides direction on a corporate level for the interface between EMMA and Excelys so that authorizations can map to claims
Responsible for expanding UM on a regional basis
Responsible for assessing the market's need for onsite concurrent review, working collaboratively with the market to place the staff in facilities
In collaboration with our UM Medical director and VP, assists in identifying and then implementing strategies to correct trends of either over or under utilization
Serves as a key member in the Clinical Services Organization's leadership team
Collaborates with operations to decrease turnaround times on authorization requests coming through the intake unit
Collaborates with appeals and grievances to identify issues with current authorization processes and to identify trends which could improve application of criteria and processes
Chairs a monthly Utilization Management meeting with representatives from all lines of business to identify and resolve issues impacting members, providers and claims payment
Ensures that we are actively engaging on Medical Director reviews and strategies when an external review source is needed so that timely medical determination can be made
Oversees UM portion of readiness reviews, External Quality Review Organization (EQRO) reviews and NCQA reviews for the markets managed by corporate UM
Serves as the primary resource for determining our future UM processes for the PEGA system conversion
Required A Bachelor's Degree in Nursing (BSN), Health Administration, Business, or related field
Preferred Other MBA, MPH or MHA
Required 7+ years of experience in acute clinical/surgical experience
Required 5+ years of management experience in a managed health care setting
Required 5+ years of experience in in progressively challenging positions
Advanced Demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
Advanced Ability to lead/manage others
Advanced Ability to work in a fast paced environment with changing priorities
Advanced Ability to create, review and interpret treatment plans
Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Advanced Other Demonstrate effective critical thinking and decision making skills
Advanced Other Ability to communicate on any level required to meet the demands of the position
Advanced Other Ability to correctly write business letters and comprehensive reports
Required Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word,Excel, Power Point and Outlook
Required Intermediate Healthcare Management Systems (Generic)

Director, Utilization Management Resume Examples & Samples

Support and perform case management, disease management and on site concurrent review functions as necessary
Coordinate efforts with the Member Services and Connections Departments to address members and providers issues and concerns in compliance with medical management requirements
Maintain compliance with National Committee for Quality Assurance (NCQA) standards for utilization management functions for the prior authorization unit
Develop, implement and maintain policies and procedures regarding the prior authorization function
Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes
Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting

Utilization Management Resume Examples & Samples

5+ years of experience as LPN/LVN required
5+ years of experience in Case Management, UM preferred
Ability to utilize a Windows PC and learn new/complex applications easily
Must have a current LPN for the State of which you reside

Director, Utilization Management Resume Examples & Samples

Bachelor's degree in Nursing or equivalent experience
1+ year of utilization management and/or case management experience
Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff

Case Manager, Utilization Management Resume Examples & Samples

Must be licensed in the state of Florida as a Registered Nurse
Associates Degree in Nursing required. Graduate of an accredited school of Nursing; Bachelor of Science in Nursing (BSN) strongly preferred
Excellent verbal and written communication skills and ability to work in a fast-paced, crisis-oriented environment
Prefer CCM or CPHM certifications
Minimum required experience: 1+ years

Director of Utilization Management Resume Examples & Samples

Responsible for utilization, quality, and continuous improvement within the job scope
Knowledge of computer programs, navigation of electronic programs (automated referral management system, CMS criteria, MCG criteria, Health Plan portal navigation)
Contributes to and supports the corporation’s Utilization and quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts
Direct oversight of the day to day activities of the Utilization management department, policies, procedures, and overall management of the team
Assist in education of the teammates and acts as resource professional
Participates in UM/QA Committee and conducts required related functions
Supports and participates in the UM/QA initiatives, plan and Committee
Participates in Health Plan, NCQA, and CMS audits
Work with other departments in a cooperative manner to achieve company goals, i.e., Inpt/opt CM teams, clinical operations, , Quality Improvement, claims, Contracting/Network Services, , Finance, and Administration
Participate in creating, developing, updating, and maintaining department policies and procedures
Supervises and participates in case finding management process (Identifying members for case management, identifying alternative resources for the referrals,) with health plan
Participates in CQI of UM Management Department
Provides input on system issues and enhancements
Investigates alternative resources for members, works with opt CM/SW team
Assists nurses in developing contacts and relationships with payers and other clients
Assists nurses in developing contacts and relationships with providers, provider’s office staff and ancillary facilities personnel
Develops a working knowledge of contracts with facilities and alternative care providers as well as Medicare and managed care organizations, benefits and contracts
Works with the Medical Directors with decision making of medical necessity cases, specialists, and primary care physicians

Manager, Utilization Management Resume Examples & Samples

Ensure compliance with established referral, pre-certification and authorization policies, procedures and processes
Facilitate ongoing communication between care management staff, utilization management staff and contracted providers
Maintain compliance with URAC, federal and state regulations and contractual agreements, including HIPAA
Develop, implement and maintain compliance regarding medical utilization management and appeals functions
Monitor the effectiveness of existing outreach and intervention efforts
Ensure appropriate medical necessity review for all levels of care and assure appropriate knowledge, education, and interventions are conducted for members defined to be at risk
Monitor data, trends and potential quality improvement opportunities including provider issues, service gaps, member needs

Manager of Utilization Management Resume Examples & Samples

Design Clinical Operations/utilization management programs and processes to meet current strategic needs and to anticipate future strategic changes
Develop and manage inpatient and outpatient care management programs throughout the continuum of care delivery. Assure programs provide for (1) cost-effective use of patient care resources and case delivery at the most appropriate level; (2) collaboration with the medical staff on resource utilization issues; and (3) compliance with utilization-related private contracts, all regulating agencies, and applicable federal and state regulatory mandates
Direct the Clinical Case Management, Concurrent Review Staff, and Pre-certification functions of the Clinical Services division. -
Develop strategic and operational plans in accordance with organizational and departmental strategic initiatives and goals
Develop, recommend and manage department budget
Lead, develop and mentor a management team. Develop staff performance plans, provide regular performance feedback, manage direct reports and perform personnel actions in accordance with policy & procedure
Model and inculcate organizational values
Direct the development, implementation, and updating the approval process for the Utilization Management Plan
Analyze and monitor quality, cost reimbursement and utilization trends. Identify problem areas, develop strategies, and recommend action plans for resolution. -
Design overall department structure such that a) staffing is appropriate and cost-effective; b) technology use is maximized; and c) staff and operational performance standards are met or exceeded
Work closely with senior management and Medical Directorate to ensure integration of Clinical Operations strategies
Facilitate interdepartmental and interdisciplinary collaboration to ensure efficient coordination of Clinical Operations
Collaborate across departments on projects, such as the design, production, and timely distribution of Clinical Support Reports, utilization reports, physician performance reports, and other reports as assigned
Experience working with related legal and regulatory requirements required - Registered Nurse with current unencumbered California license
Advanced degree in business, public health administration, or equivalent education and experience preferred - Strong computer skills
Bachelors of Science Nursing ( BSN) - 3+ years healthcare experience in a provider organization
Experience managing a team of registered nurses in a fast paced, time-sensitive environment, demonstrating the ability to motivate to continuously improve their performance with successful outcomes
Possess the ability to make independent decisions when circumstances warrant such action, deal tactfully with personnel, residents/patients, family members, visitors, etc., and seek out new methods and principles and be willing to incorporate them into existing practices
Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach
Must have patience, tact, cheerful disposition and enthusiasm and be able to relate to and work with ill, disabled, elderly, emotionally upset residents/patients and their families. -
Must be able to read, write and speak the English language
Must be able to use a computer for data entry and to send and retrieve webmail

Director, Utilization Management Resume Examples & Samples

Required a Bachelor's Degree in Nursing (BSN), or equivalent work experience
Preferred a Master's Degree in Nursing
Required current experience in utilization management to include pre-authorization, utilization review, concurrent review, discharge planning, and/or skilled nursing facility reviews
Intermediate demonstrated problem solving skills Independent problem solving to overcome barriers and meet deadlines
Intermediate ability to work within tight timeframes and meet strict deadlines
Intermediate ability to lead/manage others
Intermediate demonstrated analytical skills
Intermediate demonstrated written communication skills
Intermediate demonstrated interpersonal/verbal communication skills
Intermediate ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate demonstrate effective critical thinking and decision making skills
Intermediate ability to communicate on any level required to meet the demands of the position
Intermediate ability to correctly write business letters and comprehensive reports
Required Licensed Registered Nurse (RN) in state of practice
Preferred Utilization review/management certification, or equivalent professional certification
Required intermediate Microsoft Excel
Required intermediate Microsoft Word
Ability to use proprietary health care management system

Director of Utilization Management Resume Examples & Samples

5+ years of Utilization Management experience
Bachelor's Degree in Nursing, Business, and/or Healthcare Management
Strong Management background
Working knowledge of Interqual or Milliman
Knowledge of the Healthcare delivery system

Utilization Management Clinician Resume Examples & Samples

Responds to and completes urgent/emergent assessment and triage for members telephonically
Complete pre-certification for higher level of care admissions as part of emergency triage rotation
Application of medical necessity criteria in authorization of psychiatric and chemical dependency services. Referral and triage for members in crisis situations
Maintains a caseload of higher level of care cases(IP, RTC, PHP, IOP) and, completes concurrent reviews, scheduling MD-MD reviews as needed and coordinates with facility discharge planner on post discharge follow up care
Data entry of all authorizations and clinical notes in member files (Raintree/Flex Care)
Complete retro-reviews as assigned by UM Supervisor
Participate in scheduled staff meetings and trainings
Participates in weekly case conference
Notify Director of Utilization Management and UM Supervisor regarding any quality indicators/concerns Potential Quality Improvement (PQI) including untoward event/incidents
Current California Licensure as a Registered Nurse
Have either a current, valid, unrestricted independent license in behavioral health or nursing (RN) and practice within the scope of their licensure

Utilization Management Case Manager Resume Examples & Samples

Education:BSN required. May be an RN with BS in health related field
Experience:3 to 5 years’ experience in acute care, case management or related experience. Proficient in the application of InterQual criteria preferred
Licensure/Certification/Registration: Current Tennessee RN license or current license from a compact state. Must attend education programs to maintain required CE hours for active credentials. BLS certification must be obtained prior to employment from an approved American Heart Association training center
Skills:Hands-on experience utilizing computer programs (Microsoft Word, Excel, Meditech and/or Midas preferred). Must possess excellent documentation skills along with written and verbal communication skills. Excellent critical thinking skills, negotiating skills, ability to prioritize and multi-task necessary. Proven leadership and diplomacy skills to affect positive case management outcomes. Skilled in coaching and conflict management to maximize the achievement of case management outcomes. Near visual acuity for close paperwork; and good motor coordination required to operate photocopier, CRT and computer. Good hearing essential to operate telephone and assist physicians, office personnel and the public

Senior Utilization Management Clinician Resume Examples & Samples

Supports new business and new staff through training on systems (e.g., FlexCare, CareConnect) documentation, policies and procedures and standards of operation
Expectation of Senior UM Clinical to development expertise of UM policies and procedures working all systems (e.g., CareConnect and FlexCare)
Development of training materials
Supports Director of Clinical Services and AVP of Clinical Operations in new business and internal clinical operations implementations
Provides assistance with clinical system enhancement request, testing and training
Attend internal and external meetings as needed
Some travel maybe required based on business need
Performs telephone triage, telephonic case review in psychiatric and substance use treatment facilities as assigned
Assists with NCQA, URAC and other QI initiatives to support the Service Center
Provides assistance with Service Center Clinical Policy Review, Medical Necessity and provides training
Contributes to Corporate Clinical workgroups
Current, valid and unrestricted independent CA licensure for practice required with proof on date of hire. Re-verification will take place no less than every 3 years
A minimum of two years of Inpatient and Outpatient Utilization Management experience in Behavioral Health Care
Demonstrated experience establishing relationships and effectively engaging with members and providers through telephonic communication to obtain necessary information and facilitate care in multiple settings
Demonstrated strong UM systems and documentation knowledge (e.g. CareConnect and/or FlexCare)
Demonstrated work experience meeting strict deadlines and established cycle times through effective prioritization and follow-up skills
Demonstrated ability to work independently, train and mentor less experienced UM staff.Strong leadership and presentation skills

Utilization Management Clinician Resume Examples & Samples

3-5 years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility; Required
Managed care/utilization review experience; Preferred
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding; Required
Behavioral Health experience; Plus

Director Utilization Management Resume Examples & Samples

Directs, coordinates and evaluates efficiency and productivity of utilization management functions for physical and behavioral health services. Works closely with pharmacy and vendors to assure integration, oversight, and efficiency of UM and appeals processes and for delegated functions. In collaboration with the national clinical team, assures that all utilization management-related activities meet the standards required for the state contract and NCQA
Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets. Identifies opportunities for improvement; organizes and manages cost of care initiatives. Collaborates with local and national leaders including Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care. Provides expert input to Finance regarding patterns of utilization and cost and high cost cases
Assures staff selection, training, and evaluation to promote the development of a high quality team
Works closely with and provides input to national health plan clinical team on program design, policies, procedures, workflows, and correspondence
Collaborates with Network leaders to design and operationalize successful methods for working with hospitals, home health, and other services. Assures integration and efficiency of Network strategy and vendor relationships with utilization management and claims processes. Works closely with network on the training and evaluation of providers as well in resolving provider related issues
Directs the work of Managers, Utilization Management, who assure quality, interrater reliability and standards are met in daily operations. Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting
Member of health plan QI Committee. Co-chair of health plan Utilization Management Committee

Telephonic Utilization Management, Post Acute Resume Examples & Samples

Recommend services for Humana Plan members utilizing care alternatives available within the community and nationally
Active RN license in TX
Prior clinical in an acute care, skilled or rehabilitation clinical setting
Internet speed for work at home capability of 10Mx1M
Experience in, or strong understanding of, managed care and reviewing care plans for medical necessity
Previous experience in utilization management, discharge planning and/or home health or rehab

Utilization Management Screener Resume Examples & Samples

Responsible for quality and continuous improvement within the job scope
At the request of the prior auth nurse, requests clinical information from the medical provider as appropriate
Cover all company phone lines and assure these lines are always covered by two screeners before leaving their desk
Maintains a courteous, professional attitude when working with facility staff, providers and their staff, the health plan and co-workers
Reviews medical requests with the a nurse, manager and/or Medical Director and other team members as needed and appropriate prior to making any decisions they are unsure of
Responsible for timely and accurate documentation in the computer system
Documentation will be compliant with established standards which are monitored through audits
Responsible to document ICD-10 and CPT coding and levels of care to reflect care and services provided for claim adjudication
Works closely with nurses
Participates in internal audit reporting as necessary
Active participation in team meetings
One to two years experience in a medical environment, working knowledge of medical terminology, ICD 10 and CPT coding
This position requires experience handling heavy telephones, providing customer service to both internal and external customers and strong computer skills
Clinical and critical thinking skills are essential along with excellent problem solving and decision making abilities
Medical Terminology is recommended
Good organization and detail oriented

Director of Utilization Management Resume Examples & Samples

Assists with review of potential patients, verifying medical necessity, any special treatment needs or potential problems
Within (24) hours of patient admit, completes admission review on all assigned cases
Completes continued stay review on charts to insure that record contains documentation validating appropriateness of continued stay utilizing pre-established criteria (Content reflects severity of illness, intensity of service, patient's response to treatment and justification for continued stay)
Collects and sends summary assessments of incident reports to appropriate case workers, guardians, insurance company etc. as required
Documents and notifies responsible clinicians and supervisors of documentation deficiencies
Documents regularly in UM Case folder pertinent contacts with MCO and other payer sources to include number of days certified, date reports sent, comments/concerns of aforementioned or any other pertinent information related to the case
As part of the Continued stay review, monitors clinical documentation to insure appropriate, timely and effective provision of services, treatment planning and discharge/aftercare planning
Identifies and contacts insurance company/MCO in accordance to the insurance/MCO's guidelines
Documents all contacts with reimbursement sources, including days certified, next review date, and needed information, notifying other hospital departments as indicated
Notifies Administration, Business office, Primary therapist, Program Director and physician of any potential and/or actual reimbursement problems
Initiates appeal process in a timely manner
Monitor discharge plan development, expected discharge date, and follows up any changes to the plan with the MD and/or therapist
Acts as resource for family of patients if reimbursement in jeopardy
Attends Morning Meeting on a daily basis. Provides critical information
EDUCATION and/or EXPERIENCE
CERTIFICATIONS, LICENSES, REGISTRATIONS
MATHEMATICAL SKILLS
REASONING ABILITY
PHYSICAL DEMANDS
WORK ENVIRONMENT

Manager of Utilization Management Resume Examples & Samples

Oversight of the review process for all acute services, both in andout of network
Monitor and trend timeliness of UM decision making
Responsible for all UM audits inclusive of completing audit roadmaps, preparing files for client and regulatory agency audits
Oversight of the Peer Review processes, scheduling, and physician advisor availability in conjunction with the medical director
Oversight of clinical rounds both internally and with health plans and providers for the purpose of utilization management
Assists with new business procurement and implementation in conjunction with the clinical implementation manager. Participates in the analysis of selected utilization metrics as part of plan specific reporting requirements
Demonstrated skill in management of multi-disciplinary staff
Must be detail-oriented, able to work independently in a flexible environment,
Able to handle multiple tasks in an efficient manner
Knowledge of Medicaid products is required

Utilization Management Rep Resume Examples & Samples

Requires a high school diploma/GED
3 years of experience in customer service experience in healthcare related setting
Medical terminology training required

Manager of Utilization Management Resume Examples & Samples

Responsible for all these lines of business: all commercial business including FEP, regional, and state
Responsible for managing UM functions of members traveling in or living in other states for national accounts and administration of the BlueCard program
Manages staffing and resources to comply with turn around time standards for authorization requests received by fax, e-mail, and recorded authorization systems
Manages staffing and resources to exceed corporate expectations of regional telephone service levels
Administers productivity levels that have been established for all levels of staff
Reviews productivity standards quarterly, and continuously increases them as system upgrades accelerate the authorization process
Administers quality standards that have been established for all Utilization Management, Care Coordination and support staff
Managers rotate responsibility of the 24-hour/day call duty to process after-hour authorization requests and trouble shoot urgent and emergent needs identified by providers, members, and family members, taking calls from providers and members after hours and on weekends
FEP committee
FEP BCBSA committee
Clinical Risk committee
Regional Advisory Panel
TVA committee
Behavioral Health Interface committee
Various product development, pricing and contracting work groups according to areas of responsibility – Transplant, Home Health, Home Infusion, DME, Pre-existing, Pre-determinations, Disease Management, disease specific Case Management, etc
Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law
Minimum of 5 years of a variety of health care experience, e.g., hospital, outpatient
3-5 years combination of Utilization Management and Case Management experience
Minimum of 3-5 years of supervisory/management experience
BS degree in Nursing or related healthcare field preferred, or successful track record of management experience
Regular overnight travel is not required, but may be requested on occasion

Manager, Utilization Management Required Resume Examples & Samples

Responsible for supervision of Utilization Management Supervisors, Clinicians, and activities
Complete quarterly chart audit of Utilization Management Staff
Complete annual reviews of UM staff
Monitor caseloads/workload and performance
Assignment of after hour cases to UM staff for follow-up
Responsible for staff schedule based on staffing needs of the department
Assist with reviewing and updating UM policies and procedure
Update and educate staff of any changes to policies and procedure
Responsible for scheduling mandatory training for UM staff (Affirmative, Level of Care, Referral and Triage, Documentation, Legal, Advance Directive)
Maintain a thorough knowledge of URAC/NCQA standards and regulatory requirements
Assist/monitor consistency amongst UM staff in application of Level of Care Criteria
Assist and monitor referral and triage process and review all emergent cases with Director of UM and CHIPA Physician Advisor
Responsible for monitoring UM phone queue performance
Responsible for reviewing cases for timeliness of UM decision and notification
Responsible for coordinating clinical appeals with health plans
Responsible for reviewing and coordinating with health plans on all clinical denial and notifications
Provide weekly updates to Director of Utilization Management
Maintain a thorough knowledge of covered benefits for populations served
Participate in provider and plan meetings as assigned
Facilitate monthly staff meetings to ensure that all staffs are provided with updated information on policies& procedures, level of care criteria, and any changes in the work plan
Facilitate weekly case conferences with CHIPA Medical Director and with Health Plan Medical Directors
Responsible for management/monitoring of Medical Director and Physician Advisors weekly schedule and availability
Hiring and termination of department staff; enforcement of disciplinary procedures
Training new UM staff/new hires regarding policy and procedures and level of care criteria
Develop relationship and acting as back-up liaison with payers, providers and facilities regarding UM policies and procedures
Attend and participate in meetings (i.e., CMC, PRC, QIC), as assigned by Director of UM
Attend and participate in health plan and regulatory agency (NCQA, DMHC) audits
Participate in New Implementations (Program, Health Plan)
Prepare Materials for Health plan and regulatory agency audits
Complete urgent and emergent risk assessments as needed
Complete pre-certification for HLOC admissions as needed
Assists with concurrent reviews as needed
Complete retro-reviews and retro-authorizations for inpatient or emergency services as needed
Leadership skills and supervisory experience, including ability to develop team performance
Experience in psychiatric/chemical dependency utilization management, preferably in a hospital and /or managed care setting
Strong interpersonal skills and good written and verbal communication skills
Advanced level of PC skills required
Experience with staff supervision
Ability to manage and coordinate with internal and external departments/customers
Must be detailed oriented; able to work independently
Good understanding of UM regulatory requirements (URAC, NCQA)
Ability to understand and interpret UM metrics as well as identify new UM metrics as needed
Understanding of clinical guidelines and level of care criteria
Good understanding of Utilization Management Standards, and Policies and Procedures

Utilization Management Director Resume Examples & Samples

Develop operational programs and plans
Identify measures of success and related tactics to achieve
Identify key operational metrics needed to track progress to measures of success
Develop budget recommendations for department
Responsible to manage departmental resources to meet budget targets
Identify staffing plan and with approval execute to optimize and meet productivity goals
Ability to analyze key data metrics and adapt operations to achieve success
Ability to communicate plans and evaluations effectively in verbal and written forms
Department has well defined strategy and mechanism to evaluate performance
Budget goals are well defined and performance at or under budget is achieved
Policies and procedures are current and compliant with regulatory standards
Maintain compliance with InterQual criteria and monitoring
Daily operations are consistent with written policies and procedures
Department personal is maintained to meet operational objectives
Department leaders and staff know what is expected of them and understand how they are performing to those objectives
Department performance achieves desired operational outcomes
Areas of improvement are identified and changes are made appropriately
Accurate and timely reporting of data provided to the Health Plan and state regulatory agency within established timelines
Appropriate documentation provided to Health Choice QM department and state regulatory agency with tangible outcomes and measures of specified information and observed trends

Coord, Utilization Management Resume Examples & Samples

Responsible for accurate processing and data entry of referrals and authorizations within the time frames set for urgent and/or routine
Assigns accurate ICD-9 and CPT codes to requested services for referral and authorization processing
Verifies eligibility and benefits with internal systems and manuals or with health plans if necessary
Documents in memo and/or notes any special contractual arrangements agreed to
Directs authorizations to contracted providers whenever possible and authorizes services at proper level (i.e., in office rather than hospital if possible)
Requests additional information from providers when referral forms are incomplete
Responsible for timely processing of denials and assures that appropriate information is directed to Denial Administrator for processing of denial letters
Runs reports from EZ-Cap when requested
Provides telephone coverage when required
Fosters positive interaction and relationships with all internal departments and staff, as well as external contacts and ensures department resolution of problems
Maintains confidentiality and professionalism with all communications
High school diploma (or equivalent) preferred
1+ years experience in an IPA, or other health care company
Data entry experience in a clinical setting using medical terminology, ICD9 and CPT coding
Knowledge of EZ-Cap information system preferred
Proficiency with PC-based computer systems

Manager of Utilization Management Resume Examples & Samples

Provide innovation and input to improve member care, operational efficiency, and regulatory compliance
Facilitate training and cross-training of staff, in conjunction with corporate department, to maximize effectiveness and utilize staff to their fullest potential
Maintain department expenditures within budget and work with the ED and group Medical Director to develop the annual department budget
Oversee the Utilization Management Committee and ensure adequate representation for UM on all work teams and committees
Oversees the application of clinical criteria, performance standards and appropriateness protocols
Monitors, evaluates and provides ongoing feedback to staff, in a timely manner, regarding work performance, incorporating performance improvement goals
Prepares and/or oversees the Utilization Management Committee agendas in conjunction with the Medical Director and Administrator in accordance to standard policy
Maintains minutes and documentation of meetings and teams as assigned
Participates in Quality Improvement Committee in conjunction with QI Nurse, QI Chairperson / Medical Director
Current unrestricted California RN or LVN license
3+ years of experience in managed care
3+ years of management / supervisory experience in utilization management
Knowledge of general PMG / IPA operations
3+ years of experience in acute care( ICU,CCU,ER, med-surg)
Working familiarity with MS Word, Excel, PowerPoint
Previous hospital supervisory experience
MSN / MS preferred

Manager Utilization Management / PBA Resume Examples & Samples

Lifting
Ability to sit for extended periods at desk, computer terminal and/or meetings
Use of personal automobile to meet with providers, health plans and attend meetings
Bachelor’s degree in Nursing or Healthcare Administration
5 years clinical experience in the acute hospital care
Demonstrated working knowledge of managed care, capitation, provider payment mechanisms and member benefits
Demonstrated experience and ability to lead staff and daily operations
Demonstrated ability to develop, implement and monitor program direction and continuous performance improvement initiatives
Excellent written and verbal communication skills, customer service skills and leadership skills
Strong working knowledge of clinical practice and medical necessity guidelines
Strong analytical, problem solving, concurrent and retrospective data management and computer skills
Ability to establish good working relationships with all levels of support staff, providers, administrative staff and all other internal and external customers
Demonstrated positive personal influences on teams and customers, including the willingness to accept change proactively
Demonstrated ability to be flexible and responsive to needs of organization and possess ability to balance the needs of multiple priorities
Master’s degree in nursing, healthcare, quality or business
2-3 years of management, service line or program experience
Certified Professional in Healthcare Quality (CPHQ), Certified Case Manager (CCM) or other QM/UM/CM certification

Utilization Management Case Manager Resume Examples & Samples

Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required
Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience
Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; ORa Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience
Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years of nursing practice/experience; ORa Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required
Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 years of nursing practice/experience; OR a Doctoral degree in nursing or related field and approximately 2-3 years of nursing practice/experience

Utilization Management Clinician Resume Examples & Samples

3-5 years of direct clinical practice experience post masters degree, e.g., Alternative care setting such as inpatient or outpatient clinic/facility is required
Precertification/1-3 Years is required
Managed care/utilization review experience preferred
Strong Clinical/Crisis intervention skills are required

Utilization Management Resume Examples & Samples

Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines
Analyzes clinical service requests from members or providers against evidence based clinical guidelines
Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures
Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed
Processes requests within required timelines
Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner
Requests additional information from members or providers in consistent and efficient manner
Makes appropriate referrals to other clinical programs
Collaborates with multidisciplinary teams to promote Molina Care Model
Adheres to UM policies and procedures
Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan
3+ years hospital acute care/medical experience

Utilization Management Director Resume Examples & Samples

Experience working with multiple healthcare customers to ascertain, understand and meet their business needs
Knowledgeable about current and emerging technology, products and trends related to healthcare
Strong interpersonal and computer skills

Utilization Management Specialist Lakewood Resume Examples & Samples

Maintains and supports collaborative relationships with TCC's, Physicians and the multidisciplinary team
Attend all staff meeting when scheduled to work
Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes
Basic knowledge of medical records coding standards
Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team
Knowledge of and ability to use multiple Hospital information systems and Department's software; report and follow-up on software problems resulting in delay in work flow
Ability to use copier, fax machine and personal computer and knowledge of Microsoft Office

Director of Utilization Management Resume Examples & Samples

Evaluate patterns of care and resource use including over utilization and under-utilization of resources to assure patients are receiving effective and appropriate treatment, based on the level of care
Implement performance improvement initiatives as needed to increase the effectiveness ofresource utilization and the quality of patientcare
Monitor the results of performance improvement initiatives implemented and evaluate theireffectiveness
Co-chair Utilization Review Committee, prepare report for MEC and Governing Board
Identify needed resources with input into strategicplanning
Champion the auditing of medical records with the the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness
Ensure that a system is developed to provide continuity of care and communication with family and appropriate referral sources, and ensure the system is evaluated and reviewed regularly
Supervises and coordinates activities of the utilization review staff. Establish standards for customer relations and monitor the interactions between Case Management staff and customers to evaluate the effectiveness of customer service
Participate with ensuring that individual patients and their families are involved in the development of individualized treatment plans
Maintain an active involvement and awareness of all patient admissions, discharges and transfers
Meet regularly with program managers and the Medical Director and program staff to ensure compliance with program goals and objectives
Develop and maintain a system to minimize and address denials in consult with the facility Business Office Manager and CFO. Daily reporting of denials to CFO
Serve on Facility Committees and attend meetings as assigned
Ensure the department meets TJC, Medicare and federal and state regulatory requirements

Director of Utilization Management Resume Examples & Samples

Develops, implements and monitors policies and procedures for UM precertification, concurrent review, post service review (retrospective chart review), clinical practice guidelines, clinical protocols, and reporting quality of care issues identified during the UM process
Monitors UM decision making through reviewing results of local office quarterly case audits and annual Inter-Rater Reliability testing
In collaboration with the Assistant Vice President of Clinical Operations and the Clinical Director of CM develops and implements the UM plan in accordance with the mission, vision, values and strategic goals of the organization
Oversees UM processes with regards to specialty programs to ensure compliance with Beacon’s policy guidelines, standard operation procedures, external regulatory requirements and URAC/NCQA accreditation standards
Utilizes established benchmarks to monitor, track, and trend aggregated, product specific and plan specific UM metrics. Utilizes this information in monthly meetings with clinical managers, who are accountable for the performance of their office/team
Collaborates with the Assistant Vice President of Clinical Operations on census analysis and strategies to address
Must be an independently licensed behavioral health clinician and practice within the scope of their licensure with a minimum of 10 years of behavioral health /managed care experience
A minimum of 5 years of supervisory experience is required
Able to multitask with ease
Moderate skill level in MS Office environment (Outlook, Word, Excel, PowerPoint)
Desire to continually improve problem resolution skills
Team player with an ability to work under pressure
Ability to remain objective in all dealings with customers and maintain professional attitude at all times
Ability to prioritize tasks and accomplish them in a timely fashion
Excellent provider/customer relations skills

Manager Utilization Management Resume Examples & Samples

Assists clinical management in the development and on-going management of designated staff
Conducts recruitment, interviewing, and selection of properly qualified staff members and ensures appropriate orientation is provided
Regularly monitors the performance of care management staff. Monitors adherence to the efficiency goals for all staff including case volume, case closure rates, average handle time and other metrics
Analyzes specific utilization problems, plans and implements solutions that directly influence quality of care and cost efficiency

Utilization Management Specialist / Ummc Resume Examples & Samples

Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation
Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg)
Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner
HINN discussions/Observation Education
Assists Case Manager in Avoidable Days Collection
Assures appropriate reimbursement and stewardship of organizational and patient resources
Remains current on clinical practice and protocols impacting clinical reimbursement

Utilization Management Spec NE Resume Examples & Samples

Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems, facilitate resolution, recommend corrective action, and report results effectively
Completes Utilization Management for assigned patients with a minimum of 25-30 reviews per day
Maintains professional work standards including confidentiality, ethical principles, and professional work habits
Documents appropriately in UM notes to provide evidence that the UR process for the case was followed
Prior Utilization Management experience is preferred
Awareness of licensing and accreditation standards
Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers in regard to this topic
Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets

Utilization Management Case Manager Resume Examples & Samples

2 years' acute care clinical experience
Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
Ability to complete outpatient clinical reviews for home health, DME or pre-service requests
Experience with FACETS and/or Interqual criteria

Director, Utilization Management Resume Examples & Samples

The ideal candidate will have a plan in place regarding the structure of their department. He or she will develop templates for health plan, patient, and provider communication, and know how to manage a patient population remotely
Oversee the operations of the referral management, utilization review, prior authorization, and case management functions
Coordinate efforts with the Member Services and Connections Departments to address members’ and providers’ issues and concerns in compliance with medical management requirements
3+ years of nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment
2+ years of utilization management and/or case management experience
Licenses/Certifications: Current state’s nursing license

Coord, Utilization Management Resume Examples & Samples

Monitor due date of medical records for pend letters, ensure records are received and the request is sent for review upon receipt of request records
Discuss potential CCS cases with IPA Nurse and assist in preparation of notification to Angelique for submission to CCS
Verify DOFR risk and ensure the requested facility/provider is contracted depending on risk. If non-contracted telephone the office and inquire of an alternate setting again depending on risk and contracted provider (ASC, hospital , radiology)
Request for supporting documents are needed by the Nurse and follow up with the provider office to ensure records are received in a timely manner
PCAC – Document additional information that s required for Medical Director review – Ophthalmology history
EIOD Requests – Provide oral notification and document in the musical note
Surgical/diagnostic procedures requested in a hospital setting – Prior to sending for Nurse review telephone the office and ask if can be done in an ASC and obtain the facilities the provider has privileges at depending on risk and contracted facilities
Radiology procedures requested in a hospital setting – Prior to sending for Nurse review telephone the office and ask if can be done in a free standing radiology facility
STAT Report – Review daily and approve services on the UM Coordinator Business Rules and apply the above duties
Telephone calls to provider offices as directed by the UM Nurse
Glitch Report
Review daily and approve services on UM Coordinator Business Rules
Complete benefit checks and send request to Denial Team if appropriate for a denial or carve out letter
Medicare services that are not a covered benefit, send to the Denial Team for a denial letter
Faxed Requests
Ensure all information on the Treatment Authorization Request (TAR) is complete and accurate
Enter the request in the system within 1 business day of receipt
For services which require medical records for review, request prior to sending to the Nurse for review
Web Portal Requests
Ensure all information has been entered correctly
For services which require medical records for review, request and document in the pencil note

Director of Utilization Management Resume Examples & Samples

5+ years of experience with a Managed Care / HMO or Acute Care facility; 3+ years of Managerial experience within a Managed Care Medical Management system
Experience applying Medical Management Treatment guidelines, such as InterQual / McKesson, Milliman, Medicare, Medicaid NYS eMedNY and/or others
Experience with Data Management, System Support and Configuration
Experience with state and external accreditation Managed Care audits and reviews
Master's Degree in Nursing

Utilization Management Reviewer Resume Examples & Samples

Registered Nurse graduate from an accredited institution with an Associate Degree or Bachelor’s Degree. Master’s Degree preferred OR
LSW, LPC, LMFT licensure with a Master’s Degree
Minimum 3 years’ experience in a related clinical setting. Managed Care and Utilization Management experience required
Behavioral Health Management experience required

Manager, Utilization Management Resume Examples & Samples

Responsible for the oversight of all medical management activities ensuring consistency of services and achievement of utilization targets
Coordinate and manage the pre-determination process of medical and dental services
Work with market leadership to develop integrated service delivery to members and oversee medical management data and processes to maintain industry standards and practices
Interact with providers and staff to manage benefits aligned with NCQA and state-based regulations and CareSource policies and vision
Review and revise workflows to maximize efficiencies
Monitor productivity and utilization trends
Oversee CQI activities and ensure audits and staff feedback occur at regular intervals
Regularly report all medical management regulatory requirements
Ensure compliance with and reporting of all regulatory requirements
Maintain all medical management reporting
Trend data
Analyze and formulate recommendations based on data
Maintain and update all departmental policies and procedures
Audit predetermination requests, cases for documentation and interrater reliability per CareSource policy
Act as liaison with other departments to assist with research and intervention
Perform any other job related instructions, as requested
Bachelor’s Degree in Nursing (BSN) or related field or equivalent years of relevant work experience is required
Minimum of five (5) years of experience in one of the following is required: case management, utilization management, and/or quality improvement
Medical (utilization) management experience is preferred
Managed care experience is preferred

Director of Utilization Management Resume Examples & Samples

Provide leadership to his/her leadership team focusing on achievement of enterprise objectives and contractual delivery commitments specific to the delegated activities (including but not limited to: Utilization Management functions, utilization trends, QIO appeals processes and tracking, and provider appeals)
Manage to meaningful and relevant operating metrics and key performance indicators to facilitate ongoing evaluation in meeting established goals and objectives for the utilization management process, outcomes and member/provider satisfaction
Review analysis of relevant UM program data no less than monthly, provide recommendations for action to appropriate committee/leadership, and implement approved actions (including but not limited to: turnaround times – standard and expedited, QIO metrics, denial rates by level of care, staffing ratios, Quality Excellence Audit results)
Facilitate annual UM documents (program, work plan, policies/procedures - including medical necessity criteria, and prior year’s evaluation, including measurement of overall UM program effectiveness, using established goals, metric results, and associated benchmarks) and facilitate the adoption of these by appropriate committees
Participate in high-level customer meetings when required to represent the Health Services leadership and report on strategic initiatives to improve operations, quality and provider satisfaction
Recruit, retain and develop a strong team of leaders to provide ongoing leadership to their colleagues, ensure they understand how to pull and analyze UM metrics, and follow all defined Human Capital processes
Participate in the Quality Oversight Committee processes and subcommittees as assigned
Work with functional leadership to establish and convene appropriate governance committee(s) for the UM programs
Develop and adhere to department budget including growth planning
Support new client pre-delegation and implementation activities
Execute on delegation audit commitments per contracts and CMS/NCQA expectations
Implement management processes according to organization and department policies and procedures
Work collaboratively with key staff to identify opportunities for improvement, conduct appropriate trend analysis, and develop/implement action plans to address identified opportunities
Participate in physician, hospital, and ancillary provider education
Foster excellent working relationships with all stakeholders. Ensure compliance to all applicable regulatory and accreditation standards
Bachelor’s degree in a healthcare-related field
Active Registered Nurse (RN) or Physical Therapy (PT) license
Master’s Degree in business or healthcare-related field preferred
Minimum of 10 years managed care/health plan UM experience
Minimum of 7 years leadership/management experience with demonstrated interaction with senior leaders
Minimum of 5 years of direct clinical experience
Minimum of 3 years of demonstrated leadership of other leaders
Strong knowledge of health plan accreditation, CMS/NCQA regulatory standards, and regulatory reviews
Significant experience in operational planning/execution within a managed care organization strongly preferred
Process Improvement Training or Six Sigma Certification preferred
Accreditation/certification of UM programs preferred
Familiarity with InterQual

Director Utilization Management Review Resume Examples & Samples

Responsible for the leadership, direction and strategic vision of the Medical Management process, including utilization management and data analysis
Responsibilities also include the design, development, implementation and ongoing improvement of medical policy development
Responsible for assuring compliance with State, Federal and contractual obligations as well as NCQA requirements
Plans, organizes and directs the development and implementation of the Medical Management process in collaboration with the Regional UM Director
Ensures that the overall authorization process to include compliance with turnaround times, discharge planning, documentation and communication comply with NCQA accreditation requirements and all regulatory standards
Ensures staff are properly trained, oriented and provided with regular professional development
Registered Nurse with an Active/Clear license in the state of Florida
Bachelor’s degree or equivalent education and experience required. BSN preferred
5 to 10 years progressively responsible experience in a clinical environment, including but not limited to utilization management, case management or discharge planning
3 to 5 years of management experience required
Previous experience in managed care preferred
Proficient PC skills in a windows based environment

Manager Utilization Management Resume Examples & Samples

Assists with hiring, orienting, evaluating and supervising performance of the care management staff
Arranges schedules, evaluate caseloads and makes daily assignments
Evaluates and addresses educational needs of staff, conducts performance improvement management and issues corrective action as needed and ensures consistent applications of policies and compliance
Provides input into the department budget, policies and procedures. Assists in the development of department practices and procedures for utilization review and care transitions, ensuring compliance with managed care contracts and applicable regulations
Analyzes productivity and other outcome measures to identify opportunities for continuous improvement
Manages information systems to maximize the efficiency of care planning
Develops and monitors routine data quality validation
Acts as liaison with other review-related care management functions and communicates with departments as necessary to ensure coordination of related processes and functions
Establish relationships and act as liaison with providers as needed
Serves as a clinical subject matter expert for teams lead by other disciplines
Minimum three years of experience in utilization management, case management, or discharge planning and three years clinical experience required, with at least three years of experience in a hospital/health care setting or managed care setting including experience with data collection and performance improvement activities preferred
Previous supervisory experience in the field of care management preferred

Director of Utilization Management & Quality Resume Examples & Samples

Clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
Responsible for initiating policies and procedures and health plan audits, Case Management, UM and DM
The Director works collaboratively with the members, providers, health plans, and other departments to maximize member’s benefits within a cost effective environment
Identify compliance and quality improvement opportunities and initiate corrective actions
Assist in implementing procedures to provide excellent customer service to our clients through but not limited to communication, staffing, phone availability and service execution
Responsible for trending reports, identifying areas of concern and suggesting alternatives
Participate in onsite meetings with Facility Leadership and Providers to discuss current CM trends and how to improve patient outcomes
Current and unrestricted RN license in the State of California
3 or more years of Case Management/UM experience
3 or more years of Director/Management experience
Advanced computer proficiency in MS Office: Outlook, Word, Excel, PowerPoint
Managed Care work experience
Experience in compliance/audits, CMS regulations, NCQA

Utilization Management Specialist / Ummc Resume Examples & Samples

HINN discussions/Observation Education. Assists Case Manager in Avoidable Days Collection
Assures appropriate reimbursement and stewardship of organizational and patient resources. Actively reports opportunities to improve reimbursement and responds to relevant data
Collaborates with admitting specialists regarding authorization policies and procedures of third party payers. Remains current on clinical practice and protocols impacting clinical reimbursement
Licensure as a Registered Nurse (RN) in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, isrequired
One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred
Two years experience in acute care and four years clinical healthcare experience preferred
Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred

Utilization Management Resume Examples & Samples

Registered Nurse; minimum of five (5) years clinical experience. BSN preferred
2 years utilization management or case management experience required
Oral and written communication, Critical thinking, Organization and time management, and Customer service
Current unrestricted Registered Nurse licensure in the State of Texas

Case Manager, Utilization Management Resume Examples & Samples

Provides case management services for assigned member caseloads which includes
New York State Registered Nurse
Associate's degree in Nursing
Master's degree in related discipline
Experience in managed care, case management, identifying alternative care options, and discharge planning
Interqual and/or Milliman knowledge
Knowledge of Centers for Medicare & Medicaid Services (CMS) or New York State Department of Health (NYSDOH) regulations governing medical management in managed care
Relevant clinical work experience
Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills
Demonstrated critical thinking and assessment skills to ensure member care plans are followed
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
Demonstrated professional writing, electronic documentation, and assessment skills

Senior Manager, Utilization Management Resume Examples & Samples

Direct all areas of concurrent Utilization Management to include specialty programs, coordination/integration with strategic partners for all clinical conditions
Informs and participates in setting the strategic direction for all defined areas to achieve goals, differentiate in the market, and create value for members, providers, and Blue Shield
Accountable for the execution of cross functionally engagement to achieve goal oriented outcomes and successfully execute on strategic plan
Supports the creation of best in class utilization management programs that differentiate Blue Shield in the market with innovative solutions that embrace engagement, technology and partnership with members, providers and vendors
Responsible for implementation of inpatient concurrent review and admission avoidance strategies that are results oriented and embrace innovative thinking and execution
Accountable for the delivery of cost of health care savings in support of the annual budget for utilization management
Participate in the annual budget planning process and responsible for meeting budget targets
Assure that all units maintain established turnaround times to ensure regulatory compliance
Design and launch special projects to improve the efficiency and effectiveness of utilization management
Develop and implement short and long term strategies to improve team results, reducing administrative expenses, work cross functionally and collaboratively within Health Care Services and with key internal partners to build a high functioning, results oriented environment and organization
Leads and participate in various committees: site meetings, RM/QM, Transplant, Contracts, QI, and Ad Hoc committees as directed/needed
Incorporates system -wide strategic planning into development of policies and procedures, UM Program and UM Work Plans
Interfaces closely with the Senior Director of Clinical Services in preparation and presentation of materials for the organization wide Management Committees
Ensure ongoing staff competency with responsibility for performance evaluations, productivity metrics and staff development / performance interventions
Develops staff and expands productivity of the current department staff, including attention to process management and workflow re-designs where appropriate

Utilization Management Reviewer Resume Examples & Samples

Perform utilization management, utilization review, or concurrent review (on-site or telephonic inpatient care management
Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
Assess and interpret customer needs and requirements
Identify solutions to non-standard requests and problems
Work with minimal guidance; seeks guidance on only the most complex tasks
Act as a resource for others with less experience
An RN with 2+ years of experience in behavioral health OR Licensed Master's Degree level clinician in: Psychology, Social Work, Counseling or Marriage & Family Counseling; or Licensed Ph.D. or Licensed PsyD
Licensure must be current and unrestricted
3+ years of Managed Care and / or Clinical experience
Ability to navigate a Windows environment
Pre-authorization experience
Knowledge of Milliman Critera
Undergraduate degree

Utilization Management Director Resume Examples & Samples

He or she should have BS Nursing degree and should be an RN with established clinical skills and experience. We are looking for a subject matter expert who can also sell and add value to clients
Master’s degree in business, health administration would be a plus
Recent experience managing Utilization Management and other Medical Management operations for Blues or National health plans
5+ year’s healthcare management experience to understand the customer’s problems and how Cognizant’s capabilities address their requirements

Manager of Utilization Management Resume Examples & Samples

Dream Big, Plan Wisely
Break Down the Walls
Think Critically, Speak Up, Deliver with Pride
Inspire Through Trust, Lead By Example
Be Unstoppable
Oversees utilization management functions which include timely authorizations related to pre-certification, concurrent review, referrals, and other plan services
Develops and monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions
Collaborates with medical staff and reviews medical charts to obtain additional information required for appropriate utilization management and to solve complex clinical problems
Develops and analyzes operational and analytical reports to monitor and track operational efficiency
Properly documents utilization management activities and rationale for all decisions in electronic medical records systems
Functions as a clinical resource for the multi-disciplinary care team on an ongoing basis in order to maximize the quality of patient care while achieving effective medical cost management
Additional duties as assigned
Excellent communication, time management, critical thinking, and problem solving skills
Supervisory, training, or management experience
Experience in managed care, case management, identifying alternative care options, and discharge planning across a variety of treatment settings for high risk, complex populations
Interqual, Milliman, and/or TruCare knowledge
Knowledge of Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), or MLTCP regulations governing medical management in managed care
Intermediate Microsoft Word, Excel, Outlook, Powerpoint, Access, Adobe, Visio, and Project skills
Familiarity with PHI systems
Work experience in managed care or healthcare industry in utilization management including preauthorization of outpatient or inpatient services
Knowledge of utilization management/quality management case philosophies and reporting requirements to NY state and federal agencies
Ability to allocate, monitor, and control resources while delegating and monitoring workloads
Ability to work in a fast-paced environment while building and enhancing team productivity
Demonstrated professionalism and leadership skills along with the ability to develop, direct, and support staff

Manager Utilization Management Resume Examples & Samples

Chairs and Co-chairs local committees focused on creating, implementing and monitoring work plans to achieve UM targets and performance improvement. Provides expertise into target setting processes. Shares accountability with other medical center leadership for the daily monitoring of utilization indicators and performance, identification and escalation of problems, and initiation and evaluation of action plans for achieving medical center targets and improve the quality of care and services. Participates and provides UM expertise on local and regional committees, including UM Peer, UM Chiefs/Directors, Quality, TPMG, other departments and contracted/planned providers. Manages projects related to chart reviews
Links with the Quality Department to ensure quality improvement, risk, and safety management activities are aligned with local UM initiatives
Identifies and incorporates (as appropriate) evidence-based best/successful practices (e.g. care paths, innovative discharge planning / case management models, etc.) into efforts to improve quality of care/service and reduce costs
Ensures compliance with regulatory/accreditation (NCQA, MDQR, CMS, Medi-Cal, DMHC, DOL, JCAHO,etc.) requirements related to UM by partnering with other departments and facilitating workgroups in maintaining survey readiness
HR related activities (average 18 employees): Manages and resolves human resource, employee, department safety, and risk management issues. Responsible for all aspects of staff management including, hiring, development/training, performance reviews and terminations
Three (3) or more years of experience in management /leadership in a hospital or outpatient setting

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