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Skills

  • Denial management and appeal writing
  • Healthcare cost containment strategies
  • Claims avoidance techniques
  • Insulin medication assistance
  • Patient consultation
  • Intravenous therapy
  • Denial prevention tactics
  • Claims processing time reduction
  • Medication administration
  • Healthcare service utilization monitoring

Work Experiences

  • Collaborated with providers to expedite medical reviews, reducing the average claim processing time by 9 days.
  • Oversaw and managed 12 clinical and support staff in patient care activities while maintaining a high level of staff morale and professionalism.
  • Physical assessments, medication, and chronic disease management were all part of my care for home health patients.
  • Audited charts and reviewed clinical documents to ensure accuracy.
  • Conducted ongoing assessments to assess mental health needs and collaborated with a multidisciplinary team to create, implement, manage, and modify individualized care plans.
  • Oversaw 15 nurses and nursing activities in a 15-bed hospital, providing comprehensive nursing guidance and ensuring high levels of patient satisfaction and care.
  • Took part in educational activities such as the implementation of evidence-based practice projects, nursing competency development, and nursing simulation activities.
  • Achieved results within 2016.
  • Addressed under-utilized care.
  • Collaborated with providers to expedite medical reviews.

Summaries

  • Achieved results in 2017.
  • Costs were consistently reduced while profits were increased.
  • Professionally trained with vendor management and strategic planning abilities.
  • Achieved 53% improvement for over 16 monthly submissions.
  • Achieved a 50% improvement in interdisciplinary communication.
  • Excellent track record of resolving issues, increasing customer satisfaction, and driving overall operational improvements.
  • Registered Nurse, Arizona Board-Certified, with 9 years of experience providing high-quality care to patients in system and metric care units.
  • Achieved a 57% reversal rate.
  • Dedicated, hardworking, and experienced metric Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • Utilization Review Specialist with a passion for health screenings and treating patients with program and framework diseases.

Accomplishments

  • Led daily case conferences with interdisciplinary teams, improving communication flow and reducing delays in care plan implementation.
  • Created and maintained tracking reports for ongoing utilization metrics, which increased data transparency for product leadership initiatives.
  • Drafted detailed appeals for denied claims, securing a 22% success rate in overturning decisions on behalf of standard.
  • Worked closely with insurance payors to expedite approval times, resulting in an estimated 79% reduction in claim processing delays.
  • Led utilization management training program for 12 new staff members, improving overall department efficiency and reducing errors in claim submissions by 31%.
  • Standardized utilization review protocols across multiple departments, cutting down administrative burden and enhancing process efficiency by 50%.
  • Developed and tracked utilization metrics, contributing to a 19% reduction in readmission rates for logistics over 2015.
  • Developed automated utilization reporting tools that provided real-time insights, enhancing decision-making for sales and reducing manual work by 20%.
  • Supported 7-member team in ensuring accurate and timely utilization reviews, which contributed to improved patient outcomes and reduced administrative costs by 27%.
  • Evaluated utilization data trends to identify high-risk populations, leading to the implementation of targeted prevention programs that reduced readmissions by 72%.

Affiliations

  • Certified Utilization Review Specialist (CURS)
  • American Association for Physician Leadership (AAPL)
  • Lions Club
  • Society for Healthcare Improvement Professionals (SHIP)
  • Managed Care Nurses Association (MCNA)
  • Healthcare Compliance Association (HCCA)
  • Utilization Management Professionals Network (UMPN)
  • American Case Management Association (ACMA)
  • American College of Healthcare Executives (ACHE)
  • Certification in Case Management (CCM)

Certifications

  • Certified Medical Auditor (CMA)
  • Cisco Certified Internetwork Expert (CCIE)
  • Accredited Case Manager (ACM)
  • Certified Public Accountant
  • Certified Appeal Resolution Specialist (CARS)
  • Certified Medical-Surgical Registered Nurse (CMSRN)
  • Certified Revenue Cycle Specialist (CRCS)
  • CompTIA Security+
  • Salesforce
  • Certified Professional Coder (CPC)

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