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Behavioral Health Clinical Care Manager Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Summary

Detail-oriented Behavioral Health Manager passionate about Utilization review and supply of services for behavioral health providers in the state of Arkansas. Adept at understanding and communicating the medically necessary requirements for prior authorizations for Inpatient, Outpatient and Developmental Disability providers. Motivated team builder and supervisor focused on driving team collaboration.

Skills
  • Knowledgeable in Arkansas Medicaid Behavioral Health codes and requirements
  • Utilization review
  • Customer care and strong provider relations.
  • Performance metrics
  • Skilled in InterQual Criteria
Experience
01/2021 to Current
Behavioral Health Clinical Care Manager Advocates Westborough, MA,
  • Completed Inpatient, Outpatient and Developmental Disability Prior Authorization requests for Behavior Health providers in the state of Arkansas. Applied medical necessity criteria, InterQual Criteria and clinical judgement to researched cases to evaluate and establish determinations. Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries when needed. Referred cases to secondary review for failure to meet InterQual and Medical Necessity criteria.
  • Completed monthly turn around time report to determine contractual metrics are met. Provided manager with relevant ideas and workflows to reduce review completions over required turn around time.
  • Completed workflow for team members on how to build authorizations with in the Identifi program and trained providers regarding submitting prior authorizations within the Identifi system.
03/2020 to Current
Clinical Care Manager Advocates Worcester, MA,
  • Completed Inpatient, Outpatient and Developmental Disability Prior Authorization requests for Behavior Health providers in the state of Arkansas. Applied medical necessity criteria, InterQual Criteria and clinical judgement to researched cases to evaluate and establish determinations. Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries when needed. Referred cases to secondary review for failure to meet InterQual and Medical Necessity criteria.
  • Completed monthly turn around time report to determine contractual metrics are met. Provided manager with relevant ideas and workflows to reduce review completions over required turn around time.
  • Completed workflow for team members on how to build authorizations with in the Identifi program and trained providers regarding submitting prior authorizations within the Identifi system.
01/2018 to 03/2020
Quality Specialist Manager II Beacon Health Options City, STATE,
  • Completed quality review inspections for Inpatient and Outpatient Behavioral Health providers in the state of Arkansas.
  • Reviewed documentation, such as progress notes, Treatment plan and Psychiatric evaluations for medical necessity and referred for peer review when needed. \
  • Completed detailed report per inspection of care listing deficiencies and non-medically necessary interventions and submitted report to provider and the Office of Medicaid Inspector General when needed.
  • Increased process improvement initiatives by troubleshooting problems for corrective action to boost functionality and workflow.
  • Collaborated with management to discuss effective plans for resolving major quality problems.
07/2013 to 01/2018
Clinical Care Manager Beacon Health Options City, STATE,
  • Completed Inpatient and Outpatient Prior Authorization requests for Behavior Health providers in the state of Arkansas. Applied medical necessity criteria and clinical judgement to researched cases to evaluate and establish determinations. Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries when needed. Referred cases to secondary review for failure to meet InterQual and Medical Necessity criteria.
  • Completed on site inspection of cares for Outpatient Behavioral Health providers in the state of Arkansas. Reviewed documentation including progress notes, treatment plans and psychiatric evaluations for medical necessity. Interviewed staff and clients to determine customer satisfactions. Completed report of inspection of care findings and submitted report to the Office of Medicaid Inspector General.
  • Completed retrospective reviews for Outpatient behavioral health providers in the state of Arkansas. Requested documentation from providers for specific timeframe and reviewed documentation for medical necessity. Referred documentation to secondary review for when needed. Submitted findings from review to provider and Office of Medicaid Inspector General for recoupment of non medically necessary services.
Education and Training
Expected in
Master of Arts: Social Work
University of Arkansas At Little Rock - Little Rock, AR
GPA:
Expected in
Bachelor of Arts: Psychology
University of Arkansas, Fayetteville - Fayetteville, AR
GPA:

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Resume Strength

  • Length
  • Measurable Results
  • Personalization
  • Strong Summary
  • Target Job

Resume Overview

School Attended
  • University of Arkansas At Little Rock
  • University of Arkansas, Fayetteville
Job Titles Held:
  • Behavioral Health Clinical Care Manager
  • Clinical Care Manager
  • Quality Specialist Manager II
  • Clinical Care Manager
Degrees
  • Master of Arts
  • Bachelor of Arts

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