Um Compliance Con Sultan T

Yvonne Miller, R.N. BHCM

*** **** ***, **** ******, CA 92260

Cell: 714-***-****

*********@***.***

PROFESSIONAL SUMMARY

RN with 30 plus years’ experience in utilization management and medical management regulatory compliance. The last 10 years have been working directly on medical management compliance oversight.

Skill Highlights

Expertise in UM regulatory requirements

Expertise in delegation oversight health plan audits

Policy and Procedure development

Facilitation of UM/QI meetings

Experienced in startup – see AppleCare Medical Group and Medical Pathways below.

EXPERIENCE:

January 2015- August 2023: Optum- subsidiary of UnitedHealthGroup.

Job Title: Manager of Medical Management Compliance Oversight/ Compliance Consultant.

Primary Responsibility: Facilitation of health plan audits and design and implementation of corrective action plans.

Secondary Responsibilities:

Internal UM/QM audits

Staff education

Policy /Procedure Development/Revisions

Facilitation of medical group utilization management and quality management Committees

Oversight of new UM system transition/integration

Internal medical record audits

January 2003-January 2015: AppleCare Medical Management (ACMM). NOTE-ACMM was acquired by Optum in 2015.

Job Title: Vice President of Clinical Services

Responsibilities:

2003: Responsible for startup of new risk bearing organization including all due diligence health plan audits, policy and procedure development, startup UM departments that included medical management organizational design, physical design, equipment purchases, hiring, etc.

Directly responsible for UM/QM processes. Note: ACMM was not delegated for Appeals and Grievances but was responsible for internal tracking and outcome related activities.

P&L oversight of UM activities including the identification of cost-saving quality measures.

Internal UM/QM audits

March 1996-January 2003: Medical Pathways- Medical Management Company

Job Title: Vice President of Clinical Services

Responsibilities:

Startup activities for new medical group contracts.

Due diligence & annual health plan audits

Policy & Procedure development and maintenance

Oversight of P&L relating to UM activities

EDUCATION

Lavern University – Bachelors of Health Care Administration

Rancho Santiago College, Associate Degree in Science, RN Program

License &Certifications

Registered Nurse - State of California

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