Director of Utilization Review Behavior Health

Healthcare Management Leader and Patient Advocate

Direct Problem-Solve Evaluate

Accomplished, results-driven, and performance-focused Healthcare professional with successful 12+ year career in evaluating and managing patient care, program management, clinical coordination, and community outreach. Recognized as a multi-disciplined, team-oriented, forward-looking leader with proven expertise in staff training, with a proven skill of developing and maintaining relationships with Healthcare professionals. Demonstrated ability to independently direct operations and maintain optimal efficiency; analyzes and integrates information to make sound decisions based upon established guidelines. Excels during all complex challenges or conflicts. High bias for action, organized, and process-oriented approach that has provided proven business results and solid team performance.

CORE COMPETENCIES

Staff Training and Management

Organizational Leadership and Community Outreach

Quality, Risk Management, and Continuous Improvement

Managed Care Contracts and Compliance

Complex Problem-Solving and Case Reviews

Communication and Relationship Building

PROFESSIONAL EXPERIENCE

Utilization Review Manager, Eating Recovery Centers Oct 2015- present

Pro-active and independently gather information for reviews from the patient’s medical record; Conduct clinical reviews for complex dual diagnosis cases; Presents data in an articulate manner to managed care organizations. Complete chart audits to ensure patient is meeting criteria for the level of care requested. Facilitate physician to physician reviews with staff and managed care originations; Communicate relevant information in a timely manner to both business and clinical staff; Prepare and submit written appeals to MCO’s; Interview and train UR staff; and ensure we are in compliance with state/federal guidelines.

Behavioral Health Utilization Manager, Abraxas Youth and Family Services 2013-2015

Accurately reviews authorizations for initial residential/Inpatient stays; effectively coordinates patients care from admission to discharge; assists staff with complex case reviews. Supervises, trains, and manages clinical staff on ASAM/Interqual Criteria. Serves as primary liaison between multi-disciplinary team and Managed Care Organizations; pro-actively identifies quality improvement, risk management indicators, and occurrences; collaborates with physicians, health plans, hospitals, ancillary providers, leadership teams, and stakeholders to promote interdisciplinary teamwork that fosters goal achievement. Successfully increased residential/Outpatient census using clinical expertise.

Primary Therapist, Metropolitan Family Services, Chicago, IL 2012-2013

Completing comprehensive mental health assessments; Develop individualized treatment plans; Conduct and facilitate groups; facilitate family and individual counselling sessions; establish therapeutic relationships using both CBT and DBT techniques; Complete OTR for MCO and the IL Collaborative. Developed and implemented evidence-based curriculum for behavioral health program; provided supervision to integrated clinical care team. Promoted cost effective quality outcomes monitored across the care continuum; made decisions related to the provision of care. Demonstrated thorough understanding of program and regulatory rules; ensured program compliance with Medicaid Rule 132. Built and maintained strong relationships with Managed Care Organizations and state agencies.

SASS Therapist, Grand Prairie Service, Hazel Crest, IL 2011-2015

Conduct pre-admission psychiatric hospital screens and crisis stabilization to children and adolescents, Department of Children and Family Services’ (DCFS) wards of the state, and adult populations within 60 minutes of the call. Conduct a thorough assessment using the Psychosocial assessment, Mini mental status exam, USARF, past and present psychiatric & substance abuse history, risk assessment, and family history; Provide immediate crisis intervention, stabilization, case management and linkage to community resources.

Milieu Manager, Timberline Knolls, Lemont, IL 2009-2012

Effectively managed a case load of 15+ clients; in-charge of staff hiring, training, and development. Provided group and individual counseling for adolescent females with co-occurring disorders; conducted accurate assessments. Designed individualized treatment plans with measureable goals and objectives; established trusting therapeutic relationships.

Admissions Intake Coordinator, Metro South Hospital, IL 2008-2010

Responsible to conduct initial screening and assessment for treatment; regularly answer inbound calls on crisis intervention line to a diverse background and mixed population; provided successful crisis intervention services. Actively collaborated with treatment team and various departments for appropriate placement; assisted patients with admission documentation.

EDUCATION AND CERTIFICATIONS

Walden, Chicago, IL

Doctor of Philosophy (PhD.) in Clinical Psychology (in-process)

Governors State University, University Park, IL

Masters of Health Science, Concentration in Addictions/Mental Health

Bachelor of Arts

PROFESSIONAL AFFILIATIONS AND MEMBERSHIPS

Member, Illinois Healthcare Association

Member, Indiana Counselors Association on Alcohol and Drug Abuse (ICAADA)

CRADC, Illinois

LCPC, Eligible

License Clinical Addictions Counselor (LCAC), Indiana

ADDITIONAL SKILLS

Proficient with Microsoft Office, Quick Books, Epic, Sales Force, and Electronic Health Records.

Analytical self-starter with extensive experience in clinical care planning and coordination with emphasis in professional communication, and cross-functional teamwork across diverse disciplines.

Ability to analyze and provide strategic solutions to ensure successful outcomes.

Manages and inspires team members with diverse cultural backgrounds to achieve short and long-term company-wide initiatives; actively participates and leads community outreach initiatives.

Displays Ethical Leadership, Conflict Resolution, Critical Thinking, Team Objectives, Compliance, and Communication.

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