Gloria Bush

** **** **** *****

Murray, Utah

Hm: 801-***-****

Cell: 801-***-****

Gloria J. Bush B.S.N., CCM, MAOM (Master’s in Organizational Management)

Professional Summary:

Highly analytical healthcare management professional combining more than 30 years of work experience in clinical nursing, case management, utilization management, disease and wellness management, prior authorization, and team management with proficiency in financial management, leadership and positive clinical outcomes.

Objective:

To secure a position that will optimize my back ground, experience, education level and knowledge in Managed Care, Disease and Wellness Management, Policy Creation, all areas of UM, DM and Quality Management in Health Care Insurance Industry

Qualifications:

28+ years utilization management, case management and managerial experience in the managed care & acute hospital arena

8 years clinical experience in medical/surgical, out-patient, orthopedic, women’s health, delivery, high risk nursery and rehabilitation

Extensive background in managed care protocol and benefit interpretation, Medicaid of Utah guidelines, CMS – LCD/NCD Guidelines and Manuals (chapters)

Excellent knowledge in medical record review, auditing, identification of risk issues, strong analytical skills and organizational skills

Background with various computer programs with skills in Excel and Microsoft.

19 years’ experience in employee management for authorization, medical review, concurrent review, case management,

In depth knowledge of State and Federal government healthcare programs

Strong background in creating and implementing policy to support operational activities and procedures

Experience with working in concert with Quality Director; understanding of HEDIS, CQM, Process improvement, NCQA Quality measures for TAT, Complex Case Management, Satisfaction Surveys and Audits. Analyzing CAPS and HEDIS results in terms of Utilization Management and Case Management, Star Ratings, Risk Adjustment etc.

Solid practical experience with accreditation surveys, i.e., Joint Commission (Provider Facilities), CARF (Rehabilitation) and 5 NCQA Surveys (Medical Insurance), CMS Readiness Survey and Audits

Familiar with medical claims coding (ICD-9, CPT, HCPCS, DRG, etc) and payment process

Experience in data analysis for identifying and trending areas of risk, over and under utilization and high cost services which allows for the development of recommendations for improvements in processes for expected resolution of identified issues. Experience with STAR Ratings.

Experience in review, auditing, identification of risk issues as well as potential FWA identification

Experience:

January 7, 2023 - present PRN assistance with clinical procedures, PA, UM processes – consulting in areas of expertise, audits, Medicaid and Medicare rules and regulations

October 2nd 2017 – July 30, 2022 Support and Consulting for Utilization Management University of Utah Health Plans, Auditing, Training, writing Policy and Desk Top Procedures (SOPS)

February 2015 – September 2017 Director of Health Services, Health Choice Utah

January 2013 – March 2015: Regional Director Access to Care and Monitoring Medicare/Duals Population/Medicaid, Molina Healthcare of Utah

October 2008 – Jan 2013: Director of UM/PA Medicaid/CHIP/Medicare, Molina Healthcare of Utah

April 2004 – October 2008: Manager of the Utilization Management/Medical Affairs Department Molina Healthcare of Utah

November 1999 – April 2002: Rehabilitation Administrator of Case Management Activities, U of U Hospital

August 1996 – 1999: Director of Case Management, HealthSouth Rehab of Utah

February 1990 – 1996: Authorization/UM/UR/CM/Manager, Quality Management, CIGNA Healthcare of Utah

March 1988 – 19992: Women’s Center Post-Partum/High Risk Nursery, Labor and Delivery/Maternity

1988 – 1992: Weekend PRN, Alta View Hospital

March 1986 – March 1987: Medical Surgical PRN, Alta View Hospital

Education:

8/03 – 6/05 Master’s Degree in the Art of Management MAOM – University of Phoenix

8/00 – 9/01 Legal Nurse Consultant – Paralegal - Kaplan College

9/91 – 7/93 Bachelors Degree, Nursing - University of Phoenix

1987 – 1988 Associate Degree, Nursing – Weber State University

1986 – 1987 Licensed Practical Nurse – Salt Lake Community College

Professional Affiliations

Case Managers Association of Utah, American Association of Legal Nurse Consultants, Utah Nurses Association, President of Utah Case Managers Association 2002

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