Experience

Brighton Health Plan Solutions

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Manager, Appeals and Grievances

  • May 2023 - Present

  New York, United States



Capital Blue Cross

• Insurance
• 700 & Above Employee

• Director, Utilization Management

  • Jan 2021 - Sep 2022

  • Provides leadership and management of remote Utilization Management (UM) operational unit including Prior Authorization, Medical Claims Review and Concurrent Review • Analyzes data for significant utilization trends; partners with data analytics, medical policy, and other business areas to determine overall UM operational strategy for cost-containment and optimal member outcomes • Chairs Prior Authorization Committee, multidisciplinary group of key stakeholders, to determine optimal… Show more • Provides leadership and management of remote Utilization Management (UM) operational unit including Prior Authorization, Medical Claims Review and Concurrent Review • Analyzes data for significant utilization trends; partners with data analytics, medical policy, and other business areas to determine overall UM operational strategy for cost-containment and optimal member outcomes • Chairs Prior Authorization Committee, multidisciplinary group of key stakeholders, to determine optimal prior authorization strategy

• Manager, Preauthorization

  • May 2018 - Jan 2021

  • Provides leadership and management of remote Prior Authorization operational unit • Oversees clinical decision making and authorization process workflow of home health services, durable medical equipment, inpatient and outpatient procedures, specialty injectables and site of service • Partners with analytics team to identify trends and variances • Maintains operational reporting • Ensures appropriate policies and procedures are in place to support operational activities;… Show more • Provides leadership and management of remote Prior Authorization operational unit • Oversees clinical decision making and authorization process workflow of home health services, durable medical equipment, inpatient and outpatient procedures, specialty injectables and site of service • Partners with analytics team to identify trends and variances • Maintains operational reporting • Ensures appropriate policies and procedures are in place to support operational activities; collaborates with managers to create or revise policies • Educates, counsels, and motivates staff to optimize employee engagement and development

• Team Lead Preauthorization

  • Jan 2017 - May 2018

  • Partners with peer team lead to oversee daily operations of remote Preauthorization unit • Oversees inventory queues, monitors productivity, timeliness compliance and adherence to clinical and administrative policy guidelines • Acts as preceptor and mentor to staff by providing regular feedback regarding their performance, through evaluation and counseling • Establishes and evaluates departmental policies, desktop procedures, goals, staffing levels and caseloads

• Senior Accreditation and Compliance Consultant

  • Mar 2016 - Jan 2017

• Appeals and Grievances Resolution Nurse

  • Oct 2002 - Mar 2016

  • Conducts research and provides timely resolution of complex complaints, grievances and appeals for Medicare Advantage (Medical/Part D drug) and Commercial population



Home Health, Skilled Rehab , Hospital, Clinic

• Direct patient care nursing

  • Jul 1991 - Jul 2001

  Long-term care, pediatric home health, physician clinic, acute medical-surgical and psychiatric