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Medical Management/Utilization Management

Location:
Ponce, Ponce, Puerto Rico
Posted:
August 26, 2018

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Resume:

Dr. Mario O. García Incera 787-***-****

Colinas del Prado 1 Calle Rey Eduardo, Juana Díaz, PR 00795 ac6th6@r.postjobfree.com

Professional Profile

Highly trained unlicensed Physician, I have now achieved and maintained a less than 2% denial rate as the current Utilization Management Director/Physician Advisor, for Mennonite General Hospital in Guayama. (Reducing Denials from a 7% denials rate to a 2% denials rate on my first year) while ensuring and enhancing the adequacy of the Utilization Reviews Process. By stablishing and implementing new Utilization reviews initiatives and protocols.

Possess a strong professional, organizational, and the required interpersonal skills for effective and creative leadership to work with all levels of the Organization including physicians, committees and senior management, as well as patients and their families. With a proven ability to lead, support and build on current efforts of various groups working within the department’s scope of work. Ability to extensively communicate with outside agencies, third-party payers and regulators.

Skills & Abilities

Highly experienced in performing Concurrent Denials Management and Retrospective Appeals Management. Oversee the medical improvement program for the Hospital’s Internship Program

Overall team management to include but not limited to Productivity. Assuring clinical quality and other staff needs. Overseeing daily workflow of in patient UR clinicians, Transition of care nurses and medical social workers.

Experienced gathering clinical information and in-depth evaluation of medical records to determine if greater specificity is needed in documentation.

Clarifying and Engaging directly with the treating physician for adequate documentation and case-specific education and feedback.

Supporting Utilization Reviews Process by utilizing Evidenced Based criteria and the established medical care guidelines (Interqual & Milliman) in order to obtain the best care management for our patients.

Assists in the development, implementation and facilitation of hospital-wide strategic projects which impact Admission Opportunity, Length of Stay, Resource Utilization, Payor Reimbursement and Patient /Physician Satisfaction.

Experience in patient support, including assessment, counseling, education regarding medications and treatment, lab work, documentation with care plan for diagnosis and administration of treatment and procedures

Highly Computer skilled at managing heavy daily patient volume including triage, appointment scheduling, and patient referral. Proficient in all documentation/record maintenance/paperwork to ensure accuracy and patient confidentiality. With vast knowledge of MS Office

Excellent planning and organizational skills; Skilled in building long term relationships with all levels of hospital staff including executives and physicians.

Experience working with hospital administration creating and implementing new guidelines and patients care protocols.

Hard-working ambitious team player with great interpersonal skills, determined leadership abilities strong analytical and planning skills, combined with the ability to coordinate the efforts of many to meet all organizational goals.

Very highly skilled at learning new concepts quickly, working well under pressure, and communicating ideas clearly and effectively.

Fully Bilingual, Spanish and English

Experience

UTILIZATION MANAGEMENT DIRECTOR HOSPITAL MENONITA GUAYAMA AUGUST 2016 - PRESENT

Achievements:

Obtaining a 5% Reduction and maintained acute care 200 beds Hospital denials to less than 2% rate, by properly communicating with the payer's medical directors and physician advisors, to resolve any disputes surrounding medical necessity.

Developing stronger relationships with physician, Social Workers, Discharge planners and ancillary services to obtain better and more cost-effective results for our patients.

Establishing more accurate Utilization Review and case management Processes to comply with all of Medicare and Medicaid’s rules and regulations.

Achieved a 40% success rate on Utilization Reviews Appeal Process

Responsibilities:

Managing the efficiency of In-patient care delivery by collaborating with all levels of hospital administration including the Chief Medical Officer, medical and nursing staff, as well as hospital and clinic administration.

Responsible for directing all aspects of the Care Coordination department in order to ensure the most efficient and effective use of assigned resources in the provision of quality care coordination.

Provide operational management, leadership and strategic planning for the Case Management and Utilization Management department. Including pre-admissions review, Utilization Reviews, Social Services and discharge planning.

Developing case management protocols, collaborating with the medical department by educating physicians on how to reduce length of hospital stay, ensuring patients are in the appropriate level of care, and monitoring the appropriate use of diagnostic and therapeutic modalities.

Prepares and evaluates monthly, quarterly and annual reports of the Department's functions.

Managing all departmental needs, including Employee calendar and vacation rosters, attendance and payroll.

Working collaboratively with hospital leadership to ensure maximum performance on all hospital based performance measures. Communicate with the payer's medical directors and physician advisors as requested to resolve any disputes surrounding medical necessity.

Evaluating the appropriateness of medical necessity and the efficiency of the health care services provided according to established criteria’s or guidelines.

Actively perform proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient to reduce the Hospital’s denial rate.

Collaborate with the medical staff by educating physicians on how to reduce Hospital Stay

COORDINADOR MEDICO II HIMA SAN PABLO CAGUAS JULY 2012 – AUGUST 2016

Achievements:

Reduced and maintained a Tertieary 400 bed Hospital denials to less than 2%. By properly communicating with the payer's medical directors and physician advisors to resolve any disputes surrounding medical necessity.

Help developed our own web based Utilization Review Process System

Achieved a 50% success rate on Utilization Reviews Appeal Process

Responsibilities:

Managing the efficiency of In-patient care delivery by collaborating with all levels of hospital administration including the Chief Medical Officer, medical and nursing staff, as well as hospital and clinic administration.

Develop a collaborative, open partnerships with the directors of case management and social work, ensuring proper discharge planning and utilization management

Evaluating the appropriateness of medical necessity and the efficiency of the health care services provided according to established criteria’s or guidelines.

Actively perform proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient in order to reduce the Hospital’s denial rate.

Collaborate with the medical staff by educating physicians on how to reduce length of hospital stay.

Ensuring patients are in the appropriate level of care

Monitor the appropriate use of diagnostic and therapeutic modalities to help reduce the hospital stay.

ADJUNCT PROFESSOR EDIC COLLEGE AUGUST 2014 – AUGUST 2016

Achievements:

Over 90% passing grades on Anatomy and Physiology Students

Over 95% passing grades on Medical Terminology Students

Responsibilities:

Proactively teach and present basic anatomy and physiology concepts to various groups of technical grade students.

Proactively teach and present basic Medical Terminology concepts to various groups of technical grade students

MEDICAL ADVISER & REVIEWER ADJUSTERS, INC. AUGUST 2010 – JULY 2014

Achievements:

Obtained an over 80% success rate in transactions from hospitals liability and malpractice cases.

Responsibilities:

Properly identifying and evaluating patient’s medical records in order to obtain information regarding hospitals malpractice and liability cases

Stablished the appropriateness of the services provided by hospitals to reduce hospitals liability costs.

MEDICAL CLERK (LIAISON) HIMA HEALTH NOVEMBER 2008 – JULY 2012

Achievements:

Headed the medical clerk staff in charge of the medical tourism department.

Together with the Group administrator created Guidelines and Protocols for the accurate management of the medical tourism department at HIMA Hospitals

Responsibilities:

Serving as Liaison between company and peer organizations to coordinate the best medical treatment for our patients

In charge of peer discussion for emergency cases being transfer to our facility from abroad

Coordinate necessary services for Medical Tourism Patients

Worked hand in hand within a call center environment.

EDUCATION

CENTRO DE ESTUDIOS UNIVERSITARIOS XOCHICALCO, ENSENADA BAJA CALIFORNIA, MX

DOCTOR IN MEDICINE

May 2004

INTER AMERICAN UNIVERSITY OF PUERTO RICO, SAN GERMAN, PUERTO RICO

PRE-MEDICAL STUDIES

May 2000

REFERENCES

REFERENCES AVAILABLE UPON REQUEST



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