Utilization Review Case Manager
Resume:
ANGEL
CROSLAND
CASE MANAGER
*************@*****.***
Hartsville, SC 29550
CONTACT
SKILLS
• Records Management
• Discharge Planning
• Community Outreach
• Utilization review
• Referral Coordination
• Family Education
• Patient support
• Health History Documentation
• Needs Assessment
• Case Management
• Chronic Disease Management
• Case Planning
• Emotional awareness
• MS Office
• Progress Evaluations
• Conflict Resolution
• Home Visits and Inspections
• EMR / EHR
• Relationship Building
• Staff education and training
• Case Documentation
• Problem-Solving
Motivated professional with extensive experience providing quality patient care in a variety of healthcare settings. Demonstrated ability to quickly assess patient needs and develop comprehensive treatment plans. Adept at using electronic health records (EHR) to document patient data, maintain medical records and track treatment progress. Committed to evidence-based practice and continuing education to stay abreast of developments in the healthcare field.
PROFESSIONAL SUMMARY
Utilization Review Specialist
Cigna, Nashville, Tennessee
EXPERIENCE
September 2021 - March 2024
Created data visualizations using tools such as Tableau or Microsoft Power BI that highlighted key insights into healthcare usage trends.
•
Performed utilization review activities, including pre-authorization and concurrent reviews of services to ensure that medical necessity criteria were met.
•
Developed expertise in interpreting health plan policies and procedures related
• to utilization management.
Participated in team meetings providing updates on projects and identifying areas requiring further investigation or follow up action.
•
Analyzed data from multiple sources to identify trends in care and potential opportunities for improvement.
•
Adhered to all federal and state compliance requirements related to utilization
• review process.
Conducted retrospective reviews of medical claims and other documentation to determine the appropriateness of services rendered by providers.
•
Collaborated with providers to develop appropriate care plans for members and patients that meet their individual needs while optimizing resources available.
•
Assessed provider requests for authorization of services utilizing clinical
• judgement and evidence based guidelines.
Monitored performance metrics related to utilization review activities against established goals.
•
Communicated effectively with internal departments, external vendors, providers, members and patients, payers and other stakeholders regarding utilization management issues.
•
Utilized critical thinking skills when evaluating complex cases involving multiple
• diagnoses or treatments.
Documented correct records of clinical treatment to minimize coding errors and denied claims.
•
• Investigated individual cases to draft precise reports for third-party review.
• Patient Assessment
• Social Work
• Organization and Multitasking
• Community Resources
• Positive Attitude
• Active Listening
• Ethical Decision-Making
• Empathy and Compassion Senior Event Manager
Southern Streams Ranch LLC, Thonotosassa, Florida Developed strong relationships with patients through compassionate communication techniques.
•
Used computers to complete necessary patient charts and documentation on
• patients' progress.
Consulted and coordinated with healthcare team members to plan, implement, or evaluate patient care plans.
•
• Assisted physicians with examinations, procedures and other medical tasks. December 2014 - April 2021
Organized pre-event meetings with relevant personnel involved in executing a successful outcome thus avoiding any last minute surprises or issues onsite during an actual event day.
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Supervised vendors onsite during events ensuring they deliver according to their contractual obligations and expectations set forth prior to signing agreements.
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Maintained accurate records of expenses incurred during the course of planning an event.
•
Developed relationships with key external contacts such as venues, hotels and
• suppliers in order to ensure smooth running of all events.
• Inspected event facilities to verify conformance to customer requirements. Created detailed timelines and task lists for each event project ensuring deadlines were met.
•
• Suggested creative ideas to enhance event success.
• Developed marketing strategies to promote events and increase attendance. Coordinated with vendors, caterers, and other service providers to ensure all event needs were met.
•
Arranged availability and delivery of audio-visual equipment and displays for
• events.
Provided leadership and guidance throughout the entire lifecycle of an event from conception through completion.
•
Coordinated logistics such as catering, transportation, venue setup and teardown, security staff and audio-visual equipment rentals.
•
Collaborated with internal stakeholders to define project objectives and develop
• strategies for meeting them within budget parameters.
• Cultivated relationships with clients to set, meet, and deliver on expectations. Searched and negotiated suitable venues as per setup requirements and budget constraints.
•
Negotiated contracts with vendors to secure the best deals on services and
• supplies needed for event production.
Collaborated on goals and marketing objectives to capitalize on sales opportunities.
•
Created and maintained event expenditures and budgets to stay within requirements.
•
Utilized advanced computer skills in Microsoft Office Suite applications for
• managing data related to event planning activities. Created promotional materials including brochures, flyers and email campaigns to promote events.
•
Case Manager
Humana, Tampa, Florida
Leveraged strong relationships with venues, caterers, and vendors to secure event services at competitive prices.
•
Consulted with customers to determine objectives and requirements for
• meetings, conferences and conventions.
Analyzed customer feedback surveys to identify areas for improvement in future events.
•
Ensured compliance with local regulations related to health and safety requirements at all times.
•
Actively sought out new business opportunities by attending trade shows and
• conferences representing our organization's brand and services. Monitored trends in the industry through online research and networking activities in order to stay ahead of competition.
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• Hired, train, and supervised volunteers and support staff required for events.
• Reviewed event bills for accuracy and approved payment. Negotiated contracts with such service providers and suppliers as hotels, convention centers, and speakers.
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• Inspected event facilities to ensure that conformed to customer requirements. Promoted conference, convention and tradeshow services by performing tasks such as meeting with professional and trade associations and producing brochures and other publications.
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Monitored event activities to ensure compliance with applicable regulations and laws, satisfaction of participants, and resolution of any problems that arise.
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Consulted with customers to determine objectives and requirements for events, such as meetings, conferences, and conventions.
•
Obtained permits from fire and health departments to erect displays and
• exhibits and served food at events.
September 2015 - April 2021
Facilitated communication between clients and community-based providers or organizations.
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Collaborated with multidisciplinary teams to ensure comprehensive care for clients.
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• Provided crisis intervention for clients in need of immediate assistance. Ensured compliance with applicable laws, regulations and policies governing case management services.
•
• Assisted clients in developing goals and objectives related to their recovery plan. Supported individuals transitioning back into the community following
• hospitalization or incarceration.
Developed and implemented case management plans to meet individual client needs.
•
Promoted positive outcomes through effective problem solving skills and critical thinking abilities.
•
Utilized evidence-based practices such as Motivational Interviewing techniques
• in counseling sessions.
Educated clients on available resources within the community that can assist them with meeting their identified needs.
•
Director of Social Services
Grace Healthcare, Lake Wales, Florida
Coordinated referrals to appropriate social service agencies or healthcare providers as needed.
•
Conducted assessments to identify service needs, strengths, resources, and
• support systems for clients.
• Monitored client adherence to treatment plans, medications, appointments. Created and maintained accurate records of client progress, services provided, and other relevant information.
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Participated in weekly clinical supervision meetings with supervisor and program
• director.
• Attended trainings on new developments in the field of case management. Maintained professional relationships with colleagues in order to ensure quality care for all clients served.
•
Established and maintained relationships with other community agencies and
• organizations to meet community needs and avoid duplication of services. Provided direct service and support to individuals and clients, such as handling referral for child advocacy issues, conducting needs evaluation, and resolving complaints.
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• Directed fundraising activities and preparation of public relations materials. Planned and administered budgets for programs, equipment and support
• services.
Spoke to community groups to explain and interpret agency purposes, programs, and policies.
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Monitored progress of projects, identified areas for improvement and implemented corrective action plans when necessary.
•
Managed a caseload of up to 90 clients with diverse backgrounds and
• diagnoses.
Advocates for clients when necessary by attending meetings with representatives from various agencies or organizations.
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Assisted clients with obtaining basic needs such as housing, food, clothing, transportation, employment assistance and medical care.
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Educated clients on available community resources and how to access them
• effectively.
Participated in team meetings to discuss case management strategies for individual cases.
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August 2008 - April 2010
Resolved conflicts between staff members or between staff members and clients professionally.
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• Monitored program outcomes through data collection and analysis techniques.
• Provided crisis intervention services in emergency situations as needed. Conducted assessments of client needs and provided case management services accordingly.
•
Assessed risk factors associated with individual cases and implemented safety
• protocols as needed.
Organized training sessions for staff members on new technologies or methods used in delivering services.
•
Director of Social Services
Winter Haven Health & Rehab, Winter Haven, Florida Collaborated with other departments to ensure effective communication and coordination of services.
•
Advised senior management on strategic planning initiatives related to social
• service programs.
Coordinated inter-agency collaborations with government agencies, non-profits, and private entities.
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• Represented the organization at public forums or events where appropriate. Managed a team of social workers, providing direction, guidance and support in
• order to meet organizational objectives.
Established community partnerships with local organizations to increase access to resources for clients.
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Coordinated services for clients with community resources and service providers.
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Served as advocate for patient by providing follow-up services and coordinating
• discharge and aftercare planning.
Interviewed new residents to record social and health histories and complete intake assessments.
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Observed patient behaviors to discover any needed psychiatric or social services.
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• Completed treatment plan assessments to measure efficacy of treatment goals. Established and maintained relationships with other community agencies and organizations to meet community needs and avoid duplication of services.
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January 2005 - June 2008
Resolved conflicts between staff members or between staff members and clients professionally.
•
• Monitored program outcomes through data collection and analysis techniques. Ensured compliance with all applicable rules and regulations governing social service operations.
•
• Provided crisis intervention services in emergency situations as needed.
• Identified gaps in service provision and developed plans for improvement.
• Represented the organization at public forums or events where appropriate. Established community partnerships with local organizations to increase access to resources for clients.
•
Coordinated inter-agency collaborations with government agencies, non-profits,
• and private entities.
Assessed risk factors associated with individual cases and implemented safety protocols as needed.
•
Maintained up-to-date knowledge of relevant laws, regulations, guidelines, standards, best practices.
•
Collaborated with other departments to ensure effective communication and
• coordination of services.
Managed a team of social workers, providing direction, guidance and support in order to meet organizational objectives.
•
Organized training sessions for staff members on new technologies or methods used in delivering services.
•
Advised senior management on strategic planning initiatives related to social service programs.
•
Conducted assessments of client needs and provided case management
• services accordingly.
Served as advocate for patient by providing follow-up services and coordinating discharge and aftercare planning.
•
Coordinated services for clients with community resources and service providers.
•
Created and developed public relations strategies to promote awareness of
• organization's mission and services.
Contact this candidate