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Skills

  • Account reviews
  • Post-resolution reviews
  • Process proficiency
  • Transaction reviewing
  • Defect reviewing
  • Security event log reviews
  • Inspections and reviews
  • Delivering reviews
  • Order reviews
  • Foreclosure document review

Work Experiences

  • Achieved Top Performer for operational excellence.
  • Aligned with Texas guidelines.
  • Achieved $9 in annual savings for Ironclad Systems.
  • Decreased approval cycles by 57% days.
  • Created a metric-driven dashboard to track the cost-effectiveness of utilization management efforts, decreasing resource inefficiencies by 70%.
  • Addressed discrepancies in reimbursements.
  • Built collaborative relationships within the utilization review team.
  • Awarded Top Performer for excellence in case management.
  • Conducted thorough reviews of 11 medical cases per week, ensuring compliance with metric protocols.
  • Analyzed patient records to assess the necessity of treatments, successfully justifying 19% of high-cost interventions.

Summaries

  • Excellent track record of resolving issues, increasing customer satisfaction, and driving overall operational improvements.
  • Consistently improved operational outcomes.
  • Contributed to the overall success of the utilization review team.
  • Achieved a 49% reduction in discharge delays.
  • Achieved a significant reduction in denials.
  • Awarded Innovation Award for exceptional management.
  • Achieved a 60% increase in review accuracy.
  • Accomplished in driving cost containment within health services, saving over $3 annually by refining treatment plan reviews and eliminating unnecessary interventions.
  • Committed to operational efficiency.
  • Adept at developing audit procedures that identify gaps in service authorizations, improving operational efficiencies and reducing delays in claims processing.

Accomplishments

  • Developed an escalation process for complex cases that reduced appeals processing time by three years, improving stakeholder satisfaction by 64%.
  • Reduced denials by 56% at Northwind through implementing targeted clinical training initiatives and improving documentation expertise.
  • Incorporated advanced claim analysis methodologies that reduced rejected claim rates by 17% across 11 different specialties.
  • Created and delivered comprehensive training workshops for 8 staff on clinical documentation best practices, decreasing documentation errors by 80%.
  • 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.
  • Facilitated better alignment between clinical and administrative teams, boosting overall departmental efficiency by 81%.
  • Led a case review audit that recovered $10 in underpaid claims, significantly improving the organization's financial performance.
  • Conducted quarterly case audits to ensure compliance, which led to a 30% reduction in non-compliant submissions within one year.
  • Designed a comprehensive denial management strategy, which resulted in a 70% reduction in overall claim denials within one year.
  • Collaborated with IT and administrative staff to automate critical aspects of the review process, yielding a 57% gain in efficiency.

Affiliations

  • Healthcare Financial Management Association (HFMA)
  • Maintained active certification in Regulatory and Compliance with process
  • Association for Clinical Documentation Integrity Specialists (ACDIS)
  • National Association for Regulatory Administration (NARA)
  • International Council of Nurses
  • Case Management Society of America (CMSA)
  • American Case Management Association (ACMA)
  • Utilization Review Accreditation Commission (URAC) Member
  • Certification in Clinical Documentation Improvement (CCDI)
  • National Association of Healthcare Advocacy Consultants (NAHAC)

Certifications

  • Salesforce
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Managed Care Nurse (CMCN) by standard
  • Certified Utilization Management Professional (CUMP) by program
  • Project Management Professional (PMP)
  • Accredited Case Manager (ACM) by American Case Management Association (ACMA)
  • CompTIA A+ Technician
  • Google Certified Professional Cloud Architect
  • Certified Professional in Health Insurance and Managed Care (CPHIMC) by process
  • Certified Case Manager (CCM) by Commission for Case Manager Certification

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