Utilization Manager Resume Samples

Description :

1. Led the creation of a comprehensive Utilization Review System, integrating all insurance types and service programs to enhance operational efficiency.
2. Collaborated with clinical teams to ensure timely patient evaluations and adherence to treatment plans, resulting in improved patient satisfaction scores.
3. Conducted monthly audits of outpatient services, identifying areas for improvement and implementing corrective action plans.
4. Trained clinical staff on documentation standards and utilization review processes to ensure compliance and enhance patient care.
5. Managed eligibility verification processes, ensuring accurate beneficiary enrollment and service access.
6. Facilitated regular meetings with interdisciplinary teams to discuss case reviews and optimize patient management strategies.
7. Oversaw data collection and analysis for utilization metrics, providing actionable insights to senior management for strategic planning.

Experience

2-5 Years

Level

Executive

Education

BSN

Description :

1. Developed and executed a comprehensive Utilization Management plan to enhance patient care and operational efficiency.
2. Conducted data collection and analysis on program performance, identifying trends in healthcare resource utilization.
3. Implemented strategies for cost containment and quality improvement initiatives.
4. Provided timely reports on utilization patterns to key stakeholders, facilitating informed decision-making.
5. Performed thorough medical necessity reviews for inpatient and outpatient procedures.
6. Monitored clinical practices to identify and address over- and under-utilization of healthcare resources.
7. Served as the referral approval authority, ensuring compliance with established standards.

Experience

2-5 Years

Level

Executive

Education

BSN

Description :

1. Focused on enhancing the efficiency of publicly funded healthcare programs like Medicare and Medicaid.
2. Delivered comprehensive services for Outpatient Pre-Certification needs, including therapies and medical equipment.
3. Reviewed clinical documentation against established criteria to assess medical necessity.
4. Utilized Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) for procedure identification.
5. Managed a multidisciplinary team to ensure effective pre- and post-service reviews.
6. Played a key role in developing new business lines, ensuring compliance with NCQA and Department of Insurance standards.
7. Trained staff on best practices for documentation and compliance to improve service quality.

Experience

5-7 Years

Level

Junior

Education

MHA

Description :

1. Trained, supervised, and evaluated Utilization Review, Precertification, and Case Management staff.
2. Oversaw daily operations of the Utilization staff to ensure optimal performance.
3. Reviewed precertification requests and managed denial cases to streamline processes.
4. Collaborated with nursing teams to assess hospital census and identify intervention opportunities.
5. Coordinated care for high-risk members alongside Personal Care Coordinators.
6. Contributed to Benefit Interpretations and Technology Assessments with the Utilization Management team.
7. Prepared monthly reports for Health Services Director and maintained weekly finance reports.

Experience

2-5 Years

Level

Junior

Education

MHA

Description :

1. Facilitated the transfer of patient clinical information to precertification staff across multiple insurance carriers, ensuring accurate patient demographics and surgery authorizations.
2. Developed comprehensive ad hoc reports from internal databases to manage projects effectively through the entire lifecycle.
3. Develop and implement utilization management strategies to optimize resource allocation.
4. Streamlined the utilization process for surgery approvals, significantly enhancing turnaround times while training new utilization and billing staff.
5. Achieved a reduction in peer-to-peer discussion requests from 24 to 3 annually through meticulous documentation practices.
6. Enhanced physician scheduling and resource allocation, resulting in improved patient wait times and better utilization of physician hours.
7. Liaised with Medicare, Medicaid, and other insurance claims to ensure accurate processing in a dual Surgical Medical Billing Specialist role.

Experience

5-7 Years

Level

Executive

Education

M.S. HCA

Description :

1. Conducted utilization reviews for various levels of behavioral health care, ensuring compliance with medical necessity criteria.
2. Enhanced service delivery through effective discharge planning and quality service provisions.
3. Collaborated with peer review consultants to address clinical cases not meeting medical necessity.
4. Applied clinical expertise in crisis intervention and routine operational matters.
5. Facilitated treatment planning and crisis prevention strategies with clinical teams.
6. Presented clinical case findings to stakeholders to support decision-making processes.
7. Ensured compliance with regulatory standards through accurate documentation in clinical systems.

Experience

5-7 Years

Level

Executive

Education

MHA

Description :

1. Ensured cost-effective and quality consumer care by optimizing resource allocation.
2. Developed and executed the agency's quality management system, enhancing internal quality assurance and improvement activities.
3. Facilitate training sessions for staff on best practices in utilization management.
4. Conducted orientation sessions and on-the-job training for new employees, fostering a knowledgeable workforce.
5. Monitored services to guarantee safety and effective outcomes for individuals served.
6. Prepared and analyzed operational reports to ensure accuracy and efficiency in service delivery.
7. Utilize data analytics tools to assess and enhance operational performance.

Experience

2-5 Years

Level

Executive

Education

BSN

Description :

1. Implemented a trauma-informed approach in all patient interactions to ensure comprehensive care.
2. Complied with organizational infection control policies to maintain high standards of patient safety.
3. Documented patient behaviors and facilitated community meetings to enhance communication.
4. Performed clinical interventions and utilized evidence-based practices as necessary.
5. Collected and analyzed data from record reviews and service evaluations to inform care strategies.
6. Identified defects in quality systems and recommended process improvements.
7. Prepared detailed reports and analyses of findings for internal stakeholders.

Experience

10+ Years

Level

Senior

Education

BSN

Description :

1. Create reports for management on utilization metrics and improvement areas.
2. Secured psychiatric beds for patients in various healthcare settings, ensuring timely access to care.
3. Managed admissions, conducted concurrent reviews, and coordinated aftercare plans effectively.
4. Performed extensive data entry and management within a large client database.
5. Support case management teams in complex patient care scenarios.
6. Maintained compliance with local, state, and federal mental health laws and regulations.
7. Facilitated communication between the local Mental Health Authority and various healthcare facilities.

Experience

2-5 Years

Level

Executive

Education

BSN

Description :

1. Facilitated utilization reviews to assess treatment plans and ensure compliance with healthcare regulations.
2. Collaborated with interdisciplinary teams to optimize patient care pathways and resource utilization.
3. Analyzed patient data to identify trends and recommend improvements in service delivery.
4. Developed and monitored performance metrics to evaluate the effectiveness of utilization management initiatives.
5. Conducted staff training on best practices in utilization review and resource management.
6. Maintained up-to-date knowledge of HIPAA regulations and compliance standards.
7. Managed case documentation to support clinical decision-making and improve patient outcomes.

Experience

7-10 Years

Level

Management

Education

MHA