Case Management Utilization
Resume:
MARY MURPHY,
Centennial, CO *0122
OBJECTIVE
Serve in a peer or supervisory role working remotely with a multi-functional team of health professionals and stakeholders performing all aspects of utilization management and complex case management. Collaborate and adjudicate all denials, appeals and grievances with medical staff and all stakeholders in a virtual environment.
Work as a resource to staff members and other participants based upon 14 years of experience performing prospective, concurrent, retrospective reviews, and appeals and grievances. Analyze and project medical loss ratio for patients with complex care needs. Provide summary of medically based thorough and complete evaluations including prospective considerations of care, costs, and revenue cycles.
QUALIFICATION SUMMARY
Hospital clinical nursing experience, including ED and Med-Surg
Health plan and provider-side experience performing and assigning on-site and remote utilization management projects
Certified InterQual instructor
Worked collaboratively with providers, IPAs, QIO, and health plans in gaining an expertise of all aspects of managed care operations
Advocacy of patients or target population to assure excellence of care was being provided to all in the most appropriate level of care settings
Experience, knowledge and understanding of all universally accepted medical necessity criteria including: plan-specific criteria; LDC/NDC, CMS, M&G, and InterQual
Experienced with the nuances and attention required in the administration of benefits and care for special needs, dual eligible, diverse populations and complex case management patients
Critical thinking and problem-skills
Comfortable and competent in working with cross-functional teams
Proficient at DRG validation
Thorough understanding of the concepts of risk-sharing; delegation; HIPAA and HEDIS.
Strong leader and team player
Cognizant and supportive of Corporate financial goals
Patient Advocacy
Remote Xfinity high speed internet (10Gbps)
EXPERIENCE
2017-2022 Anthem of Colorado (Work at Home)
Reviewed records/EMRs of members with participating PCPs in the application of NCQA Quality measures to assist in the determination of STAR ratings for the physician/IPA with the health plan.
Documented review results into software system for compilation of overall STAR ratings.
Educated physician networks using best practices to improve performance and scores.
1999-2017 New West Physicians (OPTUM)
(As described in QUAILIFICATION SUMMARY)
EDUCATION
St. Joseph School of Nursing-Diploma Program
LICENSES and CERTIFICATIONS
Colorado Board of Nursing- Active and non-restricted / compact RN license #0043106
Certified InterQual Instructor
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