Utilization Review Behavioral Health
Resume:
Robert David Allara, M.D.
Apt # 106
Lake Worth, FL 33467
*************@***.***
Addiction, be it alcohol or drugs, is an insidious, often chronic, and life-threatening disease. It knows no bounds and is an equal opportunity destroyer of families, loved ones, jobs, morals and life of many afflicted. There are many disciplines that have developed over time to assist in the treatment of addiction. These disciplines developed work to help those afflicted to overcome and sustain long-term sobriety. One of the disciplines is substance abuse treatment centers across the country. The AMA finally recognized addiction as a disease in 1955. With this distinction, insurance companies began to recognize various treatment modalities. One, among others, are treatment centers created to help suffering addicts and alcoholics. A new concept that developed as these treatment centers sprung up was the payment of treatment by insurance companies. Also, how do we qualify these for treatment that insurance companies will pay for. This was the drive that brought the discipline Utilization Review into existence to assist in this qualification of substance abuse treatment and provide the basis for insurance companies to cover their treatment.
My passion is in the Utilization Review Management specialist field. I am well versed in all levels of substance abuse Behavioral Health UR, from Detox to OP levels of care and all levels in-between. I am equally able to obtain precerts for Mental Health clients as well. I am equally seasoned, as well, on Peer-to-Peer reviews and expedited and standard appeals processes as needed. I strive to obtain the highest level of care as well as the maximum length of stay for all clients. My prowess equals my aggressiveness with insurance companies from the care managers/advocates to the peer reviewing MD’s if needed.
I have extensive experience with Verification of Benefits which complements and assists me in situations of insurance claims, billing and collection issues to evaluate a situation immediately for solution-based decisions. My employment journey has been one of many hats, all of which have broadened my knowledge in behavioral health treatment. With a hard work ethic, I strive to get my daily assigned workload done, prioritizing authorizations needing completion, in a timely fashion and to prepare for next day assignments.
I work well with peers and administrative staff to synergize the work product for the UR department. I am a team player but work equally well independently, with excellent time management and multi-tasking skills. As a physician in recovery since 2007, I am quite knowledgeable with the addict/alcoholic behavioral health and mental health issues, allowing me to be a positive and vocal advocate for patients when dealing with insurance companies’ care managers during initial and/or continued stay reviews as well as M.D.s when completing peer reviews.
My utmost concern as a Utilization Review specialist is to obtain the longest lengths of stay in the highest levels of care that meets medical necessity criteria for helping individual addicts or alcoholics to achieve long-term sobriety in recovery.
Employment History:
Praesum Healthcare LLC
Utilization Review Specialist
2328 N. 10th Ave.
Lake Worth, FL 33407
June 1st to present
Understanding of all ASAM dimensional criteria, or MCO medical necessity criteria
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Performed SCA’s for company as needed.
Performed Peer to Peer reviews when allowed by insurance carriers.
Accurate MCO authorization documentation in EMR’s
Familiar with multiple EMR platforms to efficiently and accurately allow correct documentation.
Completing all peer to peer reviews with a 90% success rate including Ambetter, Evernorth and Optum
Serenity RCM
Utilization Review Specialist
403 Candlewood Commons
Howell Township, NJ 07731
March 1, 2024 to May 23, 2025
Understanding of all ASAM dimensional criteria, or MCO medical necessity criteria
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Performed SCA’s for company as needed.
Performed Peer to Peer reviews when allowed by insurance carriers.
Accurate MCO authorization documentation in EMR’s
Familiar with multiple EMR platforms to efficiently and accurately allow correct documentation.
Compass Revenue Solutions:
Utilization Review Specialist
118 Peachtree Ct. Ste. B
Peachtree City, GA 30269
October 2023 to February 2024
Expertise with live Peer 2 Peer reviews and expedited appeals with successful outcomes resulting in successful overturning of insurance (MCO) initial or continued stay denials. (Success rate~70-75 %)
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Initiated and successfully completed SCA’s for those clients without OON benefits as needed.
Well versed in adequate medical documentation in clients’ charts to allow for passing any insurance audits, preventing any recoupment demands.
Exceeded company metric standards recommended for lengths of stays in all levels of care for all payor mixes.
Accurate MCO authorization documentation in EMR
Exhibited ability to multitask when working cases to allow for timely completion of all work duties required.
Extensive understanding of ASAM dimensional criteria, or MCO medical necessity criteria.
Familiar with multiple EMR platforms to efficiently and accurately allow correct documentation.
Extensive understanding of ASAM dimensional criteria, or MCO medical necessity criteria.
United Billing Solutions:
Utilization Review Specialist
2925 10th Ave. N.
Palm Springs, FL 33461
April 10,2023 to October 2023:
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Handled high caseloads while managing precerts and concurrent reviews daily in a timely fashion.
Initiated and successfully completed SCA’s for those clients without OON benefits as needed.
Exceeded company metric standards recommended for lengths of stays in all levels of care for all payor mixes.
Exhibited ability to multitask when working cases to allow for timely completion of all work duties required.
Nextus Billing Solutions:
Utilization Review Physician Specialist
902 Clint Moore Rd.
Boca Raton, Fl 33487
October 2021 to 4/14/23.
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Handled high caseloads while managing precerts and concurrent reviews daily in a timely fashion.
Initiated and successfully completed SCA’s for those clients without OON benefits as needed.
Exceeded company metric standards recommended for lengths of stays in all levels of care for all payor mixes.
Exhibited ability to multitask when working cases to allow for timely completion of all work duties required.
Delphi Behavioral Health Group:
Utilization Review Physician Specialist
1901 W Cypress Creek Rd.
Fort Lauderdale, FL 33309
March 2019 to October 2021
Expertise with live Peer 2 Peer reviews and expedited appeals with successful outcomes resulting in successful overturning of insurance (MCO) initial or continued stay denials. (Success rate~70-75 %)
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Initiated and successfully completed SCA’s for those clients without OON benefits as needed.
Well versed in adequate medical documentation in clients’ charts to allow for passing any insurance audits, preventing any recoupment demands.
Exceeded company metric standards recommended for lengths of stays in all levels of care for all payor mixes.
Accurate MCO authorization documentation in EMR
Exhibited ability to multitask when working cases to allow for timely completion of all work duties required.
Extensive understanding of ASAM dimensional criteria, or MCO medical necessity criteria.
Willing to work on weekends as I provided weekend admission authorizations for Delphi Behavioral Health Group, as needed working remotely, averaging 16-20 admissions.
Company filed for bankruptcy.
National Transaction Corporation
Senior Account Executive
11951 NW 37th Street.
Coral Springs FL 33065
November 01, 2018 -03/2019
Involved in the development of relationships with business merchants and travel agencies nationwide.
Selling credit card merchant services
Advanced Recovery Systems, LLC
Utilization Review Management Physician Specialist
5211 NW 33rd Ave.
Fort Lauderdale, FL 33394
May 2017- September 23rd, 2018
Points of Interest:
Initiated and successfully completed SCA’s and Fed BCBS Plans Enrollment for substance abuse treatment cases.
Expertise with live Peer 2 Peer reviews and expedited appeals with successful outcomes resulting in successful overturning of insurance (MCO) initial or continued stay denials. (Success rate~70-75 %)
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facilities.
Extensive understanding of ASAM dimensional criteria, or MCO medical necessity criteria.
Well versed in adequate medical documentation in clients’ charts to allow for passing any insurance audits, preventing any recoupment demands.
Impeccable MCO authorization documentation in EMR
Educated treatment centers’ (The Recovery Village) nursing staff on how to be effective in documenting CIWAS/COWS scores and to properly document PAWS in the EMR.
Exceeded company metric standards for lengths of stays in all levels of care for all payor mixes.
Atlantic Treatment Center
Director of Utilization Review Management
2230 W. Atlantic Ave.
Delray Beach, FL 33445
March 6th, 2017 – April 16th, 2017
Assisted clinical team to understand the MCO medical necessity criteria requirements and ASAM criteria for proper documentation in EMR.
Facilitated proper and adequate medical necessity insurance requirements/documentation by treatment team.
Completed VOB’s on all potential admissions to help determine insurance admission status.
Knowledgeable using cloud-based medical billing software, CollaborateMD, and uploading patients into system quickly and efficiently.
Facility closed its doors—as a result of previous owner’s patient brokering charges---by DCF
Delray Center for Recovery
Director of Utilization Review Management
103 SE 4th Avenue
Delray Beach, FL 33483
Raul Rodriquez, M.D.
July 29th, 2016-March 3rd, 2017
Educated the primary therapists on the ASAM dimensional medical necessity criteria
Facilitated proper and adequate medical necessity insurance requirements/documentation of treatment team and facility
Completed all initial client precertification and continued stay reviews
Completed all peer to peer reviews and expedited appeals with MCO physicians (~60 % success rate)
Resigned as was reduced to per diem work and needed full time work
Good Future, Inc.
Director of Utilization Review Management
2230 W. Atlantic Ave.
Delray Beach, FL 33445
February 2016 to 7/26/16
Provided comprehensive UR services for census over 100 clients at times
Completed VOB’s on all potential admissions to help determine insurance admission status.
Completed all initial client precertification and continued stay reviews
Completed all peer to peer reviews and expedited appeals with MCO physicians
Left facility for better paying job
Treatment Helpline
Admissions Counselor/Representative
7800 Congress Ave. Suite 112
Boca Raton, FL 33487
November of 2015-February 2016
•Completed admission counseling for clients needing inpatient treatment at the treatment helpline owned facilities
• Completed comprehensive telephonic medical assessments
National Addiction Institute, LLC
Recovery Advocate/Admissions Counselor
1400 W. Cypress Creek Road Suite 401
Fort Lauderdale, FL 33403
May 2015 to November 2015
•Completed admission counseling for clients needing inpatient treatment
•Completed comprehensive telephonic medical assessments
Delray Beach IOP, Inc.
Director of Utilization Review & Admission Intakes
Assistant Operating Officer
1200 NW 17th Ave. Suite #8
Delray Beach, FL 33445
September 2014-May 2015
Points of interest:
•Performed all initial authorization and concurrent authorizations (concurrent reviews) for continued stays in the program
•Conducted all peer to peer reviews and level 1 and level 2 appeals as required/requested.
•Provided training for the individual therapists on medical necessity criteria for the different levels of care.
•Communicated with the clinical staff essential information needed for proper documentation for a clients’ chart to meet MCO MNC for the level of care.
•Completed all initial comprehensive admission intakes
Was laid off as a result of inability to have enough IOP clients to support my salary
Supportive Healthcare Inc.
Utilization Review Management Specialist
January of 2014- August of 2014
14,000 S. Military Trail
Suite 140
Delray Beach, FL 33484
Performed all initial authorization and concurrent authorizations (concurrent reviews) for continued stays in the program
• Conducted all peer-to-peer reviews and level 1 and level 2 appeals as required/requested.
• Provided training for the individual therapists on medical necessity criteria for the different levels of care.
• Communicated with the clinical staff essential information needed for proper documentation for a clients’ chart to meet MCO MNC for the level of care
Treatment Search, Inc.
Admissions Coordinator/Representative—
October of 2012 to December 26th, 2013
5100 N. Federal Highway Suite 100
Fort Lauderdale, FL 33444
•Completed admission counseling for clients needing in-patient treatment
•Completed extensive initial intakes and documented in EMR for PhD psychologist to evaluate for appropriateness of admission.
TD Eye Inc.
VP and Director of Medical Operations:
February 2012-September 2012
Boca Raton, FL 33487
•Involved Ophthalmic equipment sales
First Choice Loan Services, Inc.
Sales Associate-
April 2011-January 2012
Boca Raton, FL 33431
•Refinance of home/business mortgages
Company reorganized and branch office was closed
Peer Review Mediation and Arbitration, Inc.
Director of Physician Satisfaction Initiatives—
Dec. 2009-March 2011
Pro Med Alliance, Inc.
Liaison of PRMA, Inc.
Boca Raton, FL 33431
Points of interest:
•Instrumental in bridging information to investors on the medical aspects of the company
•Help educate potential investors on the product lines of PRMA
Cataract and Refractive Surgery Institute, Inc.
Owner & CEO
Comprehensive Ophthalmologist
Solo Practitioner/Ophthalmic Surgeon
Feb. 1999-July 2007
310 35th St. SE Suite # 11
Charleston, WV 25304
Eye and Ear Clinic of Charleston, Inc.
Ophthalmologist; Ophthalmic Surgeon
Owner; Major Partner
July 1987-Feb. 1999
1306 Kanawha Blvd. E.
Charleston, WV 25301
Education:
West Virginia University-Morgantown, WV 1975-1979
School of Pharmacy…. 1976-1979 BS Pharmacy> RPh
Post Graduate Studies:
West Virginia University—Morgantown, WV
WVU School of Medicine--'79-'83
M.D Degree obtained. -'83
INTERNSHIP:
WVU Dept. of Internal Medicine—7/83-7/84
RESIDENCY:
WVU-Dept. of Ophthalmology—7/84-7/87
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