Utilization Management Supervisor (RN)
Resume:
PATRICIA
TIERNEY
Utilization Management Supervisor
CONTACT
Waltham, 02452
*********@*******.***
SKILLS
Clinical & Utilization Management
Commercial Insurance
Medicare
Medicaid
Home Health
Hospice
PACE
Complex Care Management
Case Management
Care Coordination
Clinical Operations
Program Development
Healthcare Consulting
Microsoft Office Suite
TEAMS
Microsoft Project
Lotus Notes
Change Health Care Management
InterQual Criteria
SunGard EXP Macess
SUMMARY
Experienced RN with over 24 years in utilization management, clinical operations, and team leadership, specializing in Medicare and dual-eligible populations. Proven ability to establish utilization teams, develop protocols, and ensure quality reviews and regulatory compliance. Adept at coaching licensed clinicians, monitoring productivity, and collaborating cross-functionally. Eager to contribute expertise in healthcare management and utilization services to Mass General Brigham Health Plan.
WORK EXPERIENCE
Home Health Care Manager, WellSense Health Plan Insurance 09/2025 – 08/2026
Established a dedicated team for home health utilization management. Recruited, trained, and supervised a team to ensure comprehensive understanding of home health care benefits.
Developed protocols for staff to effectively draft denial letters. Provided ongoing support and conducted performance evaluations for team members.
Admission Liaison- RN, Care Dimensions Hospice
09/2024 – 09/2025
Managed hospice care admissions across diverse settings including inpatient acute care, rehabilitation centers, skilled nursing facilities, assisted living, independent living, and group homes.
Liaised with hospital attending physicians, nurses, and social workers to collaboratively develop hospice care plans.
Coordinated with hospice interdisciplinary teams for supplementary services and medical supplies.
Provided direct patient care during periods of low admission volume, administering treatments such as indwelling urinary catheter insertions, injections, and wound care; responded to urgent calls requiring nursing assessment and reassessment for hospice eligibility. Director of Utilization Services,
Harbor Health Services Inc. Elder Services Plan (PACE) 02/2024 – 09/2024
Diamond Cobalt Database
G Suite
QNXT
MedHOC
Altrutrista- Guiding Care
Softphone systems
Remdeia
Looker
Trizetto
OS operating systems
Android operating systems
Meditech
Alscripts
Citrix
miSecure
Tiger
Team Leadership
Staff Development
Quality Improvement
Regulatory Compliance
Licensed Clinicians
Quality Reviews
Productivity Monitoring
RN License
Managed Care
Inpatient Review
Outpatient Review
CCM
Oversaw the PACE program, focusing on delivering comprehensive community-based services to minimize inpatient care. Developed a specialized utilization team to review inpatient care, including acute and behavioral health services.
Collaborated effectively with interdisciplinary teams to enhance care coordination.
Engaged with assigned physicians to develop and revise care plans, prioritizing community-based support for members.
Services and Utilization Services Clinical Manager, Commonwealth care alliance
05/2018 – 12/2023
Established a team dedicated to managing utilization for home health care services.
Instituted a care model that empowered nurses to practice at the full extent of their state licensure.
Trained non-clinical staff to gather essential clinical information, while nurses were educated on home health care principles and medical necessity criteria, determining when physician consultation was required. Formed a specialized team to produce uniform and high-quality denial letters. Utilization Services Clinical Manager,
MASSGENERAL BRIGHAM HEALTH CARE
08/2016 – 03/2018
Directed a team of clinicians responsible for reviewing inpatient, post-acute rehabilitation, long-term care (LTC), and durable medical equipment (DME) services.
Initiated a team to conduct out-of-network service reviews. Supervised a team of 26 clinicians and 8 non-certified support staff who assisted by drafting correspondence and obtaining additional provider information.
Independent Home Care Consultant,
Independent Home Care Consultant
06/2011 – 06/2016
Provided intermittent part-time consultation (10-16 hours per month). Served as an advisor for certified home healthcare start-ups, preparing them for state and federal audits.
Commercial Utilization Services Team Manager, Tufts Health Plan 09/2011 – 06/2016
Managed a team of 18 clinicians performing inpatient and post-acute rehabilitation reviews, supported by 4 non-certified staff who assisted with correspondence and information gathering.
Oversaw a team of 12 case managers focused on engaging high-risk members and those recently discharged from acute or post-acute care. Provided comprehensive support and performance evaluations to team members.
Revamped or created "Job Aides" and policies, and established a team responsible for drafting member notices regarding service denials. Led a team that conducted out-of-network service reviews. Nurse Consultant /MAP trainer, Delta Projects, Inc. 07/2001 – 05/2016
Worked part-time, 20-25 hours per week.
Certified as a Medication Administration Program (MAP) trainer. Delivered initial and recertification training for staff requiring MAP certification. Conducted routine home audits to ensure compliance. Functioned as a Case Manager, coordinating medical care among individuals, care teams, attending practitioners, and family/legal guardians. Focused medical care on self-management of medications and diet, and understanding disease signs and symptoms.
Collaborated with ordering practitioners regarding medication efficacy, adverse effects, and new or recurring symptoms.
Clinical District Director, MULTICULTURAL CARE
08/2009 – 09/2011
Managed three offices staffed by a clinical team comprising Nurses, Physical Therapists, Occupational Therapists, Social Workers, and Home Health Aides. Rotated weekly through different offices to provide supervision and support to both office-based staff and in-home patient care.
Conducted annual performance evaluations and provided constructive feedback.
Successfully collaborated with an insurance company to recoup $560,000 in wrongful claim denials.
On-Site Utilization Review Manager,
HARVARD PILGRIM HEALTH CARE
06/2006 – 08/2009
Performed on-site reviews at skilled nursing facilities (SNF) and acute rehabilitation facilities to assess the medical necessity of the level of care. Facilitated coordination among rehabilitation attending practitioners, nurses, physical therapists, and social workers.
Collaborated with the team to establish realistic and safe discharge plans or transitions to lower levels of care.
Director of Clinical Services, LIFE PLANS, Inc.
10/2007 – 06/2008
Managed multiple teams across Massachusetts (MA) and New Hampshire
(NH).
Led the largest team in MA, responsible for quality assurance of comprehensive assessments conducted in the community for long-term care insurance eligibility.
Supervised a second team in MA focused on underwriting processes. Directed a team in NH responsible for the utilization management of long-term care services.
Managed a total team size of 22 individuals.
Ensured timeliness of operations, provided performance feedback, and conducted annual evaluations.
Director of Living Well, Medical Resources Home Health Care Corp 11/2006 – 09/2007
Established the private pay division to offer services not covered by insurance, such as personal care aide assistance.
Developed comprehensive policies and procedures for the new division. Recruited and trained new staff members.
Evaluated patient needs and developed personalized care plans. Clinical Services Training Manager / Specialty Case Manager/Training Specialist,
Tufts Health Plan
12/2002 – 10/2006
Initially served as a complex case manager, handling cases involving transplants, recent hospital discharges, telephone triage, and potential suicide interventions.
Managed a cohort of members aged 18-22, achieving a high engagement rate of 95% or above and motivating members to meet established medical goals. Transitioned to the role of clinical training manager, overseeing training for 13 departments.
Developed and delivered training programs tailored to the specific needs of each department.
Home Health Trainer/Clinical Director, Gentiva Health Services 11/2000 – 04/2003
Commenced as a manager overseeing a clinical team of nurses, occupational therapists, physical therapists, and home health aides. Directed staff scheduling, provided supervision, and offered support to staff both in homes and through annual evaluations.
Provided comprehensive training to clinical staff and home health aides to meet professional requirements.
Advanced to Director role, successfully guiding the agency through Medicare and state assessments.
Successfully collaborated with an insurance company to recoup $125,000 in wrongful claim denials.
EDUCATION
Framingham State College university, M.H.A. Framingham Northeastern University, B.S., Nursing Boston
CERTIFICATES
Certified Case Manager, The Commission for Case Manager Certification
12/2004
Board Certified for Gerontological Nursing Practice, The American Nurses Credentialing Center
10/1996
Massachusetts Certified Medication Administration Program Trainer 01/2000
American Heart Association Basic Life Support, American Heart Association
02/2024
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