Utilization Review Manager Home Care Resume

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Contact Information:

Full name

Present and permanent addresses

Telephone numbers

Email address


Objective:

Seeking a job as a senior level Accounts Executive job in Health sector utilizing ability, maintaining good communication with doctors, pharmacist, patients and administrators to ensure proper coordination.

Education:

  • Bachelor of Science Nursing, 1994, University of Phoenix, Salt Lake City, Utah
  • Associates of Science Nursing, 1991, Boise State University, Boise, Idaho
  • Practical Nursing Program, 1990, Southwest State Technical College, Alabama

License and Certificates:

  • Maryland State Board Examination for Registered Nurses-R070054
  • American Operating Room Nurses-Baltimore Chapter 1990-1991
  • National Association for Home Care 2003-2006
  • Manchester Who: Who-Honored Executive Program Member, QA RN in Home Healthcare and Treatment, 2004, 2005
  • Letter of Appreciation: Johns Hopkins Hospital Vice-President of Nursing and Patient Services, 1988.

Experience:

Delmarva Foundation, August 2006 – Present

Lead Utilization Reviewer

  • Work for Delmarva Foundation servicing Medicaid population. Assist with education of UR staff. Perform lead utilization review including prospective/ preauthorization, concurrent, retrospective cases.
  • Oversight of appropriate rehabilitative services and disease management. Educate providers, and facilities on IS/IS Criteria and Standards of Quality care.
  • Application of CPT/ICD-9 codes. Maintain compliance following HFCA, Medicaid, State laws, mandates, NCQA standards, Milliman & Robertson, Interqual criteria in all care settings.
  • Review/ oversight of appropriate admission to subacute, rehab and long term placement. Exceed national productivity standard in UR case review.

P-B Home Health Care Agency October 2002 – May 2006

QA Manager/Supervisor

  • Perform orientation and supervision of RN staff and ancillary personnel.
  • Responsible for case management, QA/Utilization review, complete coordination of services, therapeutic intervention rehabilitative procedures and overall supervision as required.
  • Case Management function with focus on proactively anticipating situations, allocation of community resources and disease management programs in cost effective manner.
  • Provide utilization review including prospective, concurrent, retrospective oversight, implement disease management programs, and coordinate quality acute and chronic clinical services.
  • Maintain compliance following HFCA, Medicaid, State laws, mandates, NCQA standards, Milliman & Robertson, BCBS guidelines, Interqual criteria and commercial insurance in various settings.

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