Health Services Manager

• Jun 2023 - Present

Clinical Review Nurse Supervisor

• Jan 2022 - Jun 2023

● Assist in the oversight/management of the utilization management review process. ● Review prospective and retrospective reviews for multiple health plans. Ensure the various delegated utilization management functions are applied for clinical guideline review and health plan regulatory turnaround times by line of business. ● Supervise a clinical review staff of 20 ensuring quality, production and compliance metrics are met or exceeded. ● Support staff growth and development thru coaching, transparency and empowerment. ● Interdepartmental coordination with the clinical education team, customer service, compliance, quality and HealthhHelp client liaisons. ● Assist with quarterly audits and quality initiatives. ● Improved overall timeliness from 77% in 2021 to 98% in 2022. ● Built strong working relations with health plans by increased communication creating a collaborative working relationship. Show less

Operations Senior Manager

• Jan 2013 - Dec 2020

• Responsible for overseeing the daily operations of the Utilization Management Department of 125+ employees including all prior authorization activities for inpatient and outpatient services.• Maintained expert knowledge of all product lines, directs the implementation of pilots, new products, enhancements and serves as a field resource for product development and management. Including achievement of customer performance guarantees.• Assured that services are delivered according to Policy and Procedure, Product and Quality Assurance standards, CMS and URAC accreditation standards. • Supported financial/capacity plans and managed the results to meet the goals.• Supported diversity by promoting diversity in selection process, employee retention, customer initiatives, and developmental plan for high performers. Show less

Manager IPA Medical Management

• Jan 2005 - Jan 2013

• Provided oversight and coordinate the utilization process to ensue adherence to the management company policies and procedures. • Assisted the director of medical management in the development, implementation and management of utilization management functions, including the prior authorization process, referral management and retrospective reviews.• Participated in monitoring quality/utilization trends• Strategic planning for assigned area of responsibility with establishing goals and objectives for department.• Served as management liaison with local health plans and medical networks to ensure operational continuity. Show less

Referral Manager

• Dec 2003 - Jan 2005

• Responsible for managing the effectiveness and sufficient support of all utilization management activities to include prospective and retrospective reviews for medical necessity and appropriateness of setting according to established policies and guidelines. • Knowledgeable in the use of Milliman Care Guidelines, InterQual, National and Local Coverage Determinations.• Contributed to department goals and objectives in containing health care costs while maintaining a high-quality medical delivery system through the principles of a prior authorization process. Show less

Utilization Review Coordinator

• Jan 1998 - Dec 2003