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Clinical Manager Behavioral Health resume example with 7+ years of experience

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

Master's Educated Nursing Professional with 9+ years experiencing in clinical leadership with expertise in chronic care and utilization management. Driven to implement strategic interventions to streamline treatment planning, care coordination and discharge planning to mitigate unnecessary hospitalization.

Skills
  • Nursing Leadership
  • Chronic Care Management
  • Clinical Appeals
  • Patient Education
  • Post Discharge Planning
  • Milliman Care Guidelines
  • InterQual
  • Advanced Care Planning
  • Medication Reconciliation & Administration
  • Regulatory Compliance
  • Medicare & Medicaid (CMS)
  • Workflow Analysis & Efficacy
  • Staff Development & Training
  • Risk Management
  • Behavioral Health & Long Term Care/Rehab
Education and Training
Capella University Minneapolis, MN Expected in 06/2019 Master of Science : Nursing - GPA :

Specialization in Informatics

Lone Star College, North Harris Houston, TX, Expected in 05/2013 Associate of Applied Science : Nursing - GPA :
Capella University Minneapolis, MN Expected in 06/2019 PhD. : Healthcare Administration - GPA :

in view

Certifications

ACLS & BLS

Experience
Icw Group - Telephonic Nurse Case Manager
Lisle, IL, 02/2020 - Current
  • Manage large caseload of complex care patients to reduce the likelihood of hospitalization and encourage long-term health stabilization.
  • Initiate comprehensive and focused assessments based on ICD-10 diagnostic coding and clinical history. Coordinate specialized care with in network providers and maintained the continuum of care to delay the progression of disease.
  • Review initial, concurrent, and retrospective review referrals based on clinical guidelines, EOBs, and member benefit plans to make clinical determinations. Close gaps in care by proactive chronic care management and discharge planning.
  • Educate patients and caregivers on treatment and medication compliance.
Peace Health - Clinical Manager, Behavioral Health
Dexter, OR, 06/2019 - Current
  • Promote effective utilization of behavioral health resources by implementing exceptional patient workflow processing within the interdisciplinary team to expedite care management.
  • Executive innovative strategies based on evidence-research nursing methodologies to reduce readmission rates, optimize treatment planning, and proactive discharge planning.
  • Facilitate implementation of quality performance indicators to ensure clinical quality outcomes. Reduced inventory loss by 150% through cost saving measures. Managed annual budget of $5.5 million with accurate financial reporting and expenditure authorization.
  • Initiated clinical staff workload delegation and audited medical documentation to ensure organizational standards of care are met.
Corvel - Telephonic Case Manager
Shreveport, LA, 02/2017 - 06/2019
  • Managed moderate to high acuity complex care patients to guide optimization of member benefits through patient education, proactive discharge planning, and in-network care coordination.
  • Initiated individualized care planning to identify therapeutic interventions to close gaps in care and meet each patient's holistic care goals.
  • Conducted ongoing patient education and care coordination based on risk stratification rating.
  • Reviewed prior authorization and concurrent review referrals based on medical criteria, ICD-10 diagnostic coding, and member explanation of benefits to establish determinations. Submitted clinical denials to physician peer review for further clinical determination of medical necessity,
Evangelical Lutheran Good Samaritan Society - Director of Nursing, Long-Term Care
Atwood, KS, 11/2015 - 02/2017
  • Supervised a dynamic team of clinical and ancillary staff to ensure daily operational needs are exceeded within $900,000 annual budget though quality assurance measures including daily productivity metrics, expenditure authorizations, and auditing.
  • Performed ongoing quality audits to maintain superior patient care and accurate clinical documentation for organizational and regulatory compliance and payor reimbursement.
  • Provided staff development and training on best practices and organizational guidelines. Guided workflow processes through block staffing models which increased patient satisfaction surveys from 83.3% to 93.16%.
National Nursing & Rehabilitation - Utilization Management Nurse I
City, STATE, 06/2013 - 10/2015
  • Conducted medical determinations for concurrent and continued stay reviews for inpatient admission.
  • Assured compliance with URAQ guidelines through timely medical review and certification of medically necessary services based on EOBs and clinical criteria.
  • Utilized MCG guidelines and CMS when clinically appropriate and redirected out of network care to in-network providers to strategize cost effective care. Referred complex care patients to case management for ongoing care coordination.
  • Submitted all pertinent documentation for peer review upon clinical appeal. Attended UM grand rounds with medical director, plan liaison and the clinical interdisciplinary team to drive positive patient outcomes and appropriate medical resource utilization.

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Resume Overview

School Attended

  • Capella University
  • Lone Star College, North Harris
  • Capella University

Job Titles Held:

  • Telephonic Nurse Case Manager
  • Clinical Manager, Behavioral Health
  • Telephonic Case Manager
  • Director of Nursing, Long-Term Care
  • Utilization Management Nurse I

Degrees

  • Master of Science
  • Associate of Applied Science
  • PhD.

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