Utilization Review Team Lead

E. Sean Smith

**** *********** **, **** *****, TX 76123

Phone: 817-***-****

Email: *********@*******.***

PROFESSIONAL SUMMARY

Creative, focused, goal–oriented professional with 16 years of experience in healthcare, which includes 10 years in senior management. Highly motivated, dedicated, focused, with excellent leadership skills and tireless work ethic. Dedicated Utilization Review professional with a history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.

SKILLS

People Management

Staff Management

Budget Control

Business Administration

Project Management

Staff Development

Financial Literacy

Team Management

Rules and regulations

Legal and Regulatory Compliance

Corporate Communications

Crisis Management

Verbal and written communication

Financial Acumen

WORK HISTORY

LEAD UR SPECIALIST 7/2024 – 7/2025

HANSEI SOLUTIONS

Maintain caseload and provide coverage for staff absences

Oversee assignment of over 140 cases

Provide daily consultation and supervision as needed for 8 staff

Hire, Orient, and Train new staff

Approve PTO and leave requests

Monitor, report, and recommend changes based on UR dashboard information

Conduct weekly UR meetings to discuss department and system issues

Work with UR to develop consistency and provide for adoption of best practices

DIRECTOR OF CLINICAL UTILIZATION REVIEW 07/2018 to 02/2019 and 10/2020 to 07/2024

Desert Hope Treatment - Las Vegas

Maintain caseload and provide coverage for staff absences

Oversee assignment of over 140 cases

Provide daily consultation and supervision as needed for 8 staff

Hire, Orient, and Train new staff

Approve PTO and leave requests

Complete 90-day and Annual Performance Evaluations

Develop and maintain system of appeals, peer review, post service claims, and reconsiderations including internal and external review escalation

Monitor, report, and recommend changes based on UR dashboard information

Conduct monthly UR meetings to discuss department and system issues

Work with UR to develop consistency and provide for adoption of best practices

Participate in Corporate UM activities

Monitor adherence to company, corporate, and department policies/procedures

Create and support positive, professional, and team-oriented environment

Other duties as assigned

Responsible and accountable for managing direct reports

Preparation and presentation of performance evaluations

Provide objective feedback to employees

Make appropriate compensation recommendations, if applicable

Provide appropriate training for department

Hold interviews for vacant positions and appropriately select candidates to fill open positions

Responsible for recommending and ensuring regulatory staffing patterns & managing annual budget

Monitor adherence to company and department policies, procedures, and practices

Create and support positive, professional, team-oriented, harassment free work environment by understanding and complying with company policies

Monitor performance with departmental KPIs

Adjust procedures to ensure departmental performance towards KPI thresholds

DIRECTOR OF ADMISSIONS 02/2019 to 10/2020

Desert Hope Treatment Center - Las Vegas

Explain Services Provided by AAC and Related Costs to potential patients and families

Conduct Telephonic Intakes

Oversee Admissions, Reception, and Transportation Departments

Made admission decisions about inquiring patients

Oversee transport of patients to and from airport

Oversee transport of patients to appointments

Maintain transportation schedule

Collaborate with nursing and medical to admit patients

Conduct weekly admissions meeting discussing admission and conversion rate with physicians, CEO, CFO, and DON

Approve PTO and leave requests

Complete 90-Day and Annual Evaluations

Monitor facility Bed Board and Transportation Requests

Supervise direct reports

Provide daily consultation and supervision as needed

Field admission inquiries after hours.

Oversee budget management for the admissions department, utilizing resources effectively while maintaining fiscal responsibility

Oversee departmental supply requests for the entire facility

DIRECTOR OF UTILIZATION REVIEW

Carrollton Springs Hospital

Provide data to senior management of insurance authorizations and denials

Oversee, track, and execute the entire appeals process for every denial

Conduct Monthly UR Data Meetings with CEO, CFO, Medical Dir, and Clinical Dir

Train clinical and nursing staff on medical necessity criteria

Train clinical and nursing staff on proper documentation to display medical necessity criteria

Prepare and present data of LCD audits in Medical Executive and Performance Improvement

Ensure data is entered for parity tracking

Collaborate with Director of Intake to ensure pre-certifications are done in timely manner

Interview and hire staff for the facility

Collaborate with CFO monthly to discuss the financial reports of the hospital.

DIRECTOR OF UTILIZATION REVIEW 04/2008 to 01/2016

Hickory Trail Hospital - DeSoto

Provide data to senior management of insurance authorizations and denials

Oversee, track, and execute entire appeals process for every denial

Ensure Local Coverage Determination (LCD) audits are properly completed

Train clinical and nursing staff on medical necessity criteria

Train clinical and nursing staff on proper documentation to display medical necessity criteria (MNC)

Prepare and present data of LCD audits in Medical Executive and Performance Improvement meetings

Ensure data is entered for parity tracking

Collaborate with Director of Intake to ensure pre-certifications are done in timely manner.

INTER. DIRECTOR OF RISK MGMT/PERFORM. IMPROVEMENT 02/2015 to 12/2015

Hickory Trail Hospital - DeSoto

Maintain data on all incident reports and establish any trends

Complete internal investigation of incidents in hospital

Track completion of weekly leadership rounds

Monitor proper completion of Q15 rounds for 78 patients

Respond to any 'Quality of Care' concerns by insurance companies or state

Tour with surveyor during visits by Texas Joint Commission (TJC).

PROGRAM MANAGER 07/2006 to 02/2008

Texas Mentor - Garland

Coordinate administrative functions and clinical functions

Manage program by implementing rules, regulations, and organization policies

Manage intake, referral and discharge processes for program site

Coordinate and oversee foster home development program

Supervise recruiting staff

Supervise and support administrative staff

Responsible for budgeting and financial allocations

Responsible for marketing organization and office

Liaison to licensing and governing body

Maintain complete working knowledge of Minimum Standards

Child Placing Agency Administrator License (Expired)

EDUCATION

Lamar University Master of Business Administration – Concentration in Healthcare Administration – Anticipated Graduation December 2026

UNIVERSITY OF ILLINOIS - Urbana, IL Master's of Education in Adult Education/Training and Development

05/1994

UNIVERSITY OF ILLINOIS - Urbana, IL Bachelor's of Arts, Speech Communications

05/1993

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