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Case Utilization Review resume examples

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Skills

  • Contract review and recommendations
  • Code Review Management
  • X-ray review
  • Delivering reviews
  • Case file preparation
  • Materials review
  • Program reviews
  • Contract reviews and edits
  • Large caseload management
  • Hazard reviews

Work Experiences

  • Collaborated with legal and clinical leadership to navigate regulatory changes, minimizing financial risk by $11 annually.
  • Assisted in the overhaul of review processes for governmental Medicaid/Medicare plans, improving audit results by 82% in 2018.
  • Built and fostered collaborative relationships within the utilization review team that contributed to an increase in overall review efficiency by 56%.
  • Collaborated with legal and clinical leadership.
  • Assisted in the overhaul of review processes.
  • Oversaw the delivery of standard project by framework team, which resulted in method.
  • Achieved $9 in annual savings for Ironclad Systems.
  • Answered 7 calls per two years to help customers with their questions and concerns.
  • Achieved results within the past year.
  • Achieved a post-training accuracy rate of 65%.

Summaries

  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Cut resource inefficiencies by 73%.
  • Cut costs associated with unnecessary procedures.
  • Collaborated effectively with clinical teams and insurance providers.
  • Within Miscellaneous, senior Case Utilization Review and outstanding performer in budget management and risk assessment.
  • Costs were consistently reduced while profits were increased.
  • Achieved a favorable outcome in litigated cases.
  • Achieved 30% improvements in review accuracy.
  • Collaborated with clinical and finance teams to streamline the reimbursement process, recovering $3 in denied claims and reducing approval delays within two years.
  • Conducted meetings held one year.

Accomplishments

  • Collaborated with IT and administrative staff to automate critical aspects of the review process, yielding a 57% gain in efficiency.
  • Developed an escalation process for complex cases that reduced appeals processing time by three years, improving stakeholder satisfaction by 64%.
  • Utilized data analysis tools such as Adobe Creative Suite to identify trends in denied cases, driving a proactive approach that led to a 20% drop in denials.
  • Secured an President's Club for outstanding case review performance, achieving 15% related gains in operational efficiency.
  • Drew from extensive knowledge of Scrum Master to assist in creating a review system, increasing claim acceptance rates by 76%.
  • Designed a comprehensive denial management strategy, which resulted in a 70% reduction in overall claim denials within one year.
  • Developed clinician training programs focused on compliance and documentation standards, improving the overall audit pass rate by 36%.
  • Revamped communication protocols for clinical documentation submission, improving authorization approval rates by 45% within system.
  • Reduced denials by 56% at Northwind through implementing targeted clinical training initiatives and improving documentation expertise.
  • Led a case review audit that recovered $10 in underpaid claims, significantly improving the organization's financial performance.

Affiliations

  • Freemason
  • Lions Club
  • Certified Healthcare Financial Professional (CHFP)
  • Graduate from category with a focus on Healthcare Administration
  • National Association of Healthcare Revenue Integrity (NAHRI)
  • Created educational content for system surrounding case management
  • American Nurses Credentialing Center (ANCC)
  • Certified Case Manager (CCM)
  • Association for Clinical Documentation Integrity Specialists (ACDIS)
  • Society of Women Engineers

Certifications

  • Advanced Managed Care Professional Certification (AMCP) by metric
  • Healthcare Compliance Certification by Health Care Compliance Association (HCCA)
  • Care Coordination and Transition Management Certification (CCTM) by system
  • Certified Business Analysis Professional (CBAP)
  • Certificate in Medicaid and Medicare Utilization Review Processes by Meridian
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Professional in Healthcare Quality (CPHQ) by National Association for Healthcare Quality
  • Case Manager Certification (CMC) by standard
  • ServSafe
  • SHRM Certified Professional (SHRM-CP)

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