Case Manager Clinical Quality

Rosemarie A. Crawford, BSN, RN, CCM

248-***-**** *******@*******.***

CASE MANAGER

A dedicated and results-driven Utilization and Case Manager with 15+ years of leadership experience in healthcare settings. Proven expertise in managing clinical and non-clinical teams, ensuring compliance, and optimizing operations. Recognized for exceptional organizational, communication, and leadership skills.

CORE COMPETENCIES

Leadership & Team Management NCQA, State, & Federal Guidelines Staff Training & Development

Performance Metrics Development Policy & Procedure Implementation Clinical & Administrative Oversight

PROFESSIONAL EXPERIENCE

Optum Home and Community (UHC) Clinical Team Member 2019 – 2025

Direct UM Prior Authorization Nurses, Inpatient Care Managers, and Clinical Coordinators. Oversee compliance and service timelines, ensuring adherence to performance metrics. Conduct clinical audits and implement process improvements.

Trained and mentored staff, fostering development and team collaboration.

Provided leadership in projects and ensured accurate reporting on KPIs.

Reliable Medical Solutions Manager – Clinical Quality Health 2017 – 2019

Partnered with administration in quality, process improvement, and organizational initiatives. Measured patient satisfaction, clinical quality, efficiency, effectiveness, and financial performance.

Developed, trained, and monitored clinical staff.

Molina Healthcare of MI Utilization Manager Case Manager 2006 – 2017

Utilization Management/Complex Case Management

Ensured adherence to company policies, NCQA, and federal guidelines. Guided the development of innovative solutions to enhance patient outcomes. Recruited and trained staff with a focus on professional development.

Supervised concurrent reviews, prior authorizations, and case transitions.

Led efforts to reduce denials and implement corrective actions.

EDUCATION

Mini-MBA in Healthcare – University of Arizona

Bachelor of Science (BS), Nursing – University of Detroit Mercy

PROFESSIONAL DEVELOPMENT

Certified Case Manager ICD-10, CPT, DRG, BLS, InterQual/Reimbursement Process

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