Utilization Management Supervisor

Supervisor ~ Registered Nurse

Health Services Utilization Management

Qualifications Profile

Highly organized and accomplished professional, offering comprehensive experience in directing clinical health services and operations; backed by proven success in supervising high-risk NICU insurance and utilization management operations, while implementing successful programs in the hospital setting

Areas of Expertise

Quality Patient Care

Medicaid and CMS Monitoring

Medical Regulatory Compliance

Strategic Planning and Assessment

Case and Utilization Management

Continuous Process Improvements

Healthcare Operations Management

Hospital Admission and Discharge Planning

Trends and Reports Analysis

NICU and Pediatric Cases Handling

Professional Experience

Progeny Health, Plymouth Meeting, PA

Utilization Management (UM) Supervisor Jan 2018–Present

Render keen supervision to a remote team composed of clinical and non-clinical staff

Carried out key functions, such as performance management

Conducted trends and reports analysis to closely monitor workflow and volume

Efficiently handle different markets within one health plan, while organizing meetings with staff, peers, health plans, and performance manage staff to reduce advanced length of stay in the NICU population

Career Highlights:

Earned selection and recognition for two quarters with peer impressions to the company for the smooth implementation of a new market and teamwork

Successfully implemented a very large client within three-months of employment

Aetna Better Health of Illinois, Chicago, IL (2015–2018)

Clinical Health Supervisor Dec 2016–Jan 2018

Oversaw the high-risk OB Neonatal Intensive Care members responsible for the utilization management (UM) and case management (CM) of high-risk pregnancy and NICU-related members

Set strategic direction to a team of four nurses focused on completing cases within the required turnaround time, while serving as key resource to the HROB/NICU Team and other departments regarding obstetric and pediatric cases

Facilitated weekly team meetings and weekly medical director rounds, as well as allocated case management to high-risk OB/NICU members

Took charge of conducting audits, scheduling team meetings, updating key process, working closely with providers, and acting key point of contact in all medical and NICU concerns

Collaborated with all other departments in ensuring smooth operations of UM and CM departments

Career Highlights:

Successfully established and streamlined guidelines for the Maternity NICU Team’s process

Earned nomination for a silver award for implementing the institution’s mission and values

Played significant roles as team lead and interim supervisor upon leave of the previous supervisor for the HROB/NICU Team

Succeeded in accomplishing the yellow belt certification in the Six Sigma Program

Utilization Management (UM) Clinical Consultant Case Manager Registered Nurse Apr 2015–Dec 2016

Supported the director and manager on Healthcare Effectiveness Data and Information Set (HEDIS) and request for proposal (RFP) questionnaire

Thoroughly analyzed all incoming clinical reports to identify admission and continued inpatient stay in adherence to the Milliman Care Guidelines

Partnered with medical directors and other staff members in managing plan for continued medical stay

Solely maintained daily operations of UM and CM work in compliance with process and workflow

Proactively provided emotional support, education, and guidance to new mothers and high-risk obstetric patients

Offered effectual assistance to hospital discharge planners in meeting discharge needs

St. Alexius Medical Center, Alexian Brothers Women & Children's Hospital, Hoffman Estates, IL

Registered Nurse International Board Certified Lactation Consultant Jun 1985–Apr 2015

Delivered quality nursing care to critically ill and premature infants, while creating and executing individualized care plans

Coordinated with the Medical Team on daily management functions and participated in daily medical rounds

Supervised weekly multidisciplinary planning meetings

Assumed accountability in analyzing patients’ discharge needs, arranging appointments, and educating families

Ensured strict compliance with a wide array of guidelines including Joint Commission, Health Insurance Portability and Accountability Act (HIPAA), Illinois Department of Public Health (IDPH), and American Academy of Pediatrics (AAP)

Career Highlights:

Succeeded in developing and implementing key programs involving:

-NICU-based lactation program that provided optimal outcomes in nutrition and education; and

-NICU-based discharge planning program

Education

Associate’s Degree in Nursing

William Rainey Harper College, Palatine, IL

Professional Development

Certification

Cardiopulmonary Resuscitation (CPR) Certification, Valid Until: Sep 2018

Neonatal Resuscitation Program (NRP) Certification, Valid Until: Sep 2018

Training

QNXT and Dynamo Computer Charting Systems, Aetna Better Health of Illinois

Activities

Nurse, March of Dimes: 2011

Technical Acumen

Microsoft Office Suite (Word, PowerPoint, Outlook, and Excel)

QNXT CareWeb Qi Dynamo Software Internet Applications

Contact this candidate