Case Manager Utilization Review
Resume:
CE
CAROLYN E. CARTER
***********@*****.*** 216-***-**** Brook Park, Ohio 44142
Registered Nurse and Certified Case Manager with over 10 years of experience in healthcare. Expertise in utilization review, continuous assessments, and clinical records management. Committed to promoting patient wellness and providing empathetic support to families. Seeking to contribute strong attention to detail and clinical review skills to a forward-thinking organization.
Clinical expertise
Medical causation knowledge
Treatment protocol application
Physician advisory programs
Workers' Compensation understanding
Third-party administration
File organization
Customer focus
Communication skills
Relationship management
Technology utilization
HealthSpan
Utilization Review Nurse
11/2015 - 07/2015
Company Overview: formerly Kaiser Permanente Foundation Duties included approving referrals to specialists for the members and procedures using the member's benefits to determine what their benefits allowed under their insurance plan utilizing Milliman Clinical Guidelines
(MCG) and Occupational Disability Guidelines and Health Span's Medical director to determine medical necessity.
Reviewed and completed clinical appeals as per the guidelines, for eg. NCQA, MCG, InterQual, etc.
Responsible for appeals and denial after reviewing the concerned documents.
Formerly Kaiser Permanente Foundation
CompCare / University Hospitals
Beachwood, OH
Case Manager
08/2003 - 11/2010
Office-based telephonic medical case management with emphasis on early intervention, return to work planning, coordination of quality medical care on claims involving disability and medical treatment as well as in-house medical reviews as applicable to claim handling laws and regulations. Responsible for helping to ensure injured parties receive appropriate treatment directly related to the compensable injury or assist claim handlers in managing medical treatment to an appropriate resolution. Contact medical provider and injured parties on claims involving medical treatment and /or disability to coordinate appropriate medical care. Develop medical management strategy and give the provider information necessary to facilitate a return-to-work plan on claims requiring disability management.
Responsible for ongoing evaluation of treatment and return-to-work plan, within established protocols.
Work with medical providers and suggest cost-effective treatment Objective
Computer Skills
Employment History
alternatives, when appropriate.
Help ensure that all injured parties are on an aggressive treatment plan. Authorize medical treatment and associated diagnostic testing on assigned claims as allowed by state or policy jurisdictions. For nurses handling Workers' Compensation Claims, perform Utilization Review according to established guidelines. Utilize physician advisor program.
Proactively manage medical expenses by partnering with specialty resources to achieve appropriate claim outcomes (SIU, Legal, Risk Control, Disability Management, IME and Peer Review vendors, Major Case, etc.) Obtain medical records from providers telephonically during initial contact and follow up with written correspondence if necessary. Discuss medical information and disability status with claim handler and integrate into overall strategy to ensure appropriateness of indemnity payments. Provide technical assistance and act as a resource for claim handling staff.
Contact employer to initiate modified duty or full return to work. Obtain job description and discuss job modifications required to ensure a prompt return to work.
Identify cases requiring task assignments to field case managers, discuss with supervisor for assignment to Medical or Vocational Case Manager, or vendor.
Document all contacts and outcomes related to case activity in system. Submit billing reports on all activities per established guidelines. Provide feedback to Preferred Provider Network regarding provider nominations and experience with providers.
Comply with established Best Practices.
Perform other duties as required.
10+ years Disability case management
Colorado Technical University
MBA in Health Service Management
GPA: 3.5
Ursuline College
BA in Health Service Management
Cuyahoga Community College
Associate in Applied Nursing
Cuyahoga Community College
Associate in Arts, Certified Nurse Case Management
Registered Nursing License, Multi-State, including Ohio, RN201852 Strong clinical background
Knowledge of medical causation and relatedness, as well as use of medical treatment protocols and physician advisor/peer review programs.
Certificates/Degrees
Certifications
Other Relevant Skills
Understanding of Workers' Compensation laws and Third-Party Administration File Management
Customer Focus/ Communication
Relationship Management
Use of Technology
Title: RN, BA, MBA, CCM
RN
BA Health Service Management
MBA Health Service Management
CCM
Appropriate license per state regulation
10+ years Disability case management
Personal Information
Certificates Degrees
Additional Work Experience
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