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Medicaid Utilization Review Analyst Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
Accomplishments
  • Certifications:.
Professional Summary
Highly motivated Sales Associate with extensive customer service and sales experience. Outgoing sales professional with track record of driving increased sales, improving buying experience and elevating company profile with target market.
Skills
  • Guest services
  • Inventory control procedures
  • Merchandising expertise
  • Loss prevention
  • Cash register operations
  • Product promotions
Work History
Medicaid Utilization Review Analyst, 01/2011 to Current
Brightspring Health ServicesHouston, ,
Conduct audits and investigations of Medicaid providers for appropriateness of billing and utilization. Obtain and review documentation from providers. Compare documentation and services to legal and ethical standards. Services that do not meet criteria are recouped. Agencies that are significantly out of compliance may have their contract terminated or cases submitted for prosecution. Findings are presented to providers and/or their legal representative. Represent the Department of Health and Welfare in cases that go to hearing. Position requires a solid understanding of laws and regulations, as well as the ability to discuss said rules with audit findings in complex situations to potentially hostile persons.

Program Supervisor, 03/2005 to 01/2011
Airbus HelicopterAnaheim, CA,
Developmental Disabilities team supervisor. Responsible of administration of the following programs within Idaho’s Region III: Intensive Behavioral Intervention (IBI). Children’s Service Coordination (CSC), Court-Related Duties, Guardianships, Commitments, Liaison to Idaho State School and Hospital. Includes eligibility determination, treatment plan approval and review, training of providers and agencies, quality assurance of therapy and agencies. Quality assurance surveys of Developmental Disabilities Agencies (DDA) and EPSDT Service Coordination (ESC) agencies providing services to children. This would include file reviews, therapy observations, summary report write up and presenting findings at exit meetings. Responsible for private agencies’ quality assurance and respond to complaints regarding compliance to IDAPA regulations.  Provide expert technical support to families and private agencies. Participate as regional expert in developmental disabilities services in administrative hearings as requested by the Deputy Attorney General’s office. Liaison for the Department for all regional issues involving parents, providers, law enforcement personnel, school districts. Currently involved in the following work groups: a) Idaho State School and Hospital b) Benefit Redesign. Wrote contract and coordinated weeklong training provided by behavior intervention. Provide trainings and presentations to parents and providers.
Analyst, to
, ,
  • Conduct audits and investigations of Medicaid providers for appropriateness of billing and utilization.
  • Obtain and review documentation from providers.
  • Compare documentation and services to legal and ethical standards.
  • Services that do not meet criteria are recouped.
  • Agencies that are significantly out of compliance may have their contract terminated or cases submitted for prosecution.
  • Findings are presented to providers and/or their legal representative.
  • Represent the Department of Health and Welfare in cases that go to hearing.
  • Position requires a solid understanding of laws and regulations, as well as the ability to discuss said rules with audit findings in complex situations to potentially hostile persons.
Field Program Manager, 04/2005 to Present
San Antonio, TX,
Regional Program Specialist, to
Kindercare, ,
  • Developmental Disabilities team supervisor.
  • Responsible of administration of the following programs within Idaho's Region III: Intensive Behavioral Intervention (IBI).
  • Children's Service Coordination (CSC), Court-Related Duties, Guardianships, Commitments, Liaison to Idaho State School and Hospital.
  • Includes eligibility determination, treatment plan approval and review, training of providers and agencies, quality assurance of therapy and agencies.
  • Quality assurance surveys of Developmental Disabilities Agencies (DDA) and EPSDT Service Coordination (ESC) agencies providing services to children.
  • This would include file reviews, therapy observations, summary report write up and presenting findings at exit meetings.
  • Responsible for private agencies' quality assurance and respond to complaints regarding compliance to IDAPA regulations.
  • Provide expert technical support to families and private agencies.
  • Participate as regional expert in DD services in administrative hearings as requested by the Deputy Attorney General's office.
  • Liaison for the Department for all regional issues involving parents, providers, law enforcement personnel, school districts.
  • Currently involved in the following work groups: a) Idaho State School and Hospital b) Benefit Redesign.
  • Wrote contract and coordinated weeklong training provided by behavior intervention.
  • Provide trainings and presentations to parents and providers.
  • Liaison between Department and parents, provider agencies, law enforcement agencies, and external/internal task forces.
  • Supervisor of Regions III administration of the following programs:.
  • Intensive Behavioral Intervention (IBI).
  • Children's Service Coordination.
  • Guardianships/court-related duties.
  • Department representative regarding Federals and state rules and regulations.
  • Particular emphasis on IDAPA.
  • Provide technical assistance and clinical guidance on provision of DD services overseen by the Department.
  • Audit private agencies for quality assurance and compliance with regulations.
  • Review, approve and monitor agency's plans of correction.
  • Respond to, investigate and follow up on complaints presented to the Department by parents, other providers, or other institution.
  • Participate as content matter expert for the Department in due process hearings.
  • Testify in court regarding the Department's court-related activities.
  • Supervise staff that respond to court guardianships and placement crises.
  • Wrote and monitored contract to provide a $25,000, week-long training provided by the Institute for Applied Behavior Analysis (IABA).
  • Periodically conduct presentations to other agencies within the Department, providers, and families regarding parenting education as well as rule or programmatic changes within the Department.
  • Developed method of providing IBI tracking by integrating eligibility documents with annual review progress.
  • Routinely participate in development of Department policies and creation of IDAPA regulations.
  • Currently working on: developing Community Support Outreach procedure, Benefit Redesign Program, pending Medicaid Management.
Supervisor, 01/2004 to 04/2005
American Red CrossRogers, AR,
  • Supervisor: Brenda Grupe, Program Specialist.
Psychosocial Rehabilitation Specialist, 04/2003 to 01/2004
, ,
Job Descriptions, to
, ,
  • Member of Assertive Community Treatment (ACT) Team.
  • Treatment of severely mentally ill persons.
  • Treatment plan development and review.
  • evaluation, conduct periodic treatment plan reviews.
  • Assisting persons with severe mental illness to live outside of an institutional setting.
  • Interpret and comply with state, federal regulations.
  • Familiarity with Medicaid and Social Security guidelines required.
Psychosocial Rehabilitation Specialist, 07/1995 to 04/2003
Tulalip Casino IncEl Paso, TX,
  • Supervisor: Annette Wilkinson, Developmental Disabilities Program Supervisor Case Manager and EPSDT Service coordination of over 40 cases.
  • Facilitate writing and monitoring of the Individual Family Treatment Plan (IFSP) with multidisciplinary team and private providers.
  • Ensure compliance with state and federal Special Education guidelines to include the Individuals with Disabilities Education Act (IDEA) and Part C.
  • Qualified Mental Retardation Professional (QMRP) and.
  • Conduct bi-monthly presentation of Fetal Alcohol Syndrome and prenatal drug exposure.
  • Establishing Intensive Behavioral Intervention (IBI) program within the region; including eligibility, treatment plan approval, agency review.
  • Assist IBI treatment providers in abiding by established regulation.
  • Interpret DHW, state, federal, and program rules and regulations.
  • Assist in review of provider facilities and group homes for Medicaid, legal, and ethical treatment compliance.
Psychosocial Rehabilitation Specialist, 05/2000 to 07/2001
Burrell Behavioral HealthAshland, WI,
  • Behavior modification of children and adolescents with Mental Health diagnoses.
  • Implemented behavior modification techniques in the home and community environment.
  • Taught parents techniques to allow for better parental control.
  • Conducted behavioral observation and Functional Analysis of Behavior.
  • Participate in Multidisciplinary Team Meetings to best coordinate treatment.
Summer Boyd, Shelter Manager, to
Burrell Behavioral HealthJacksonville, FL,
Youth Worker/Tracker, 10/1997 to 01/2000
, ,
  • Participate in the care of "at risk" juveniles residing in the shelter.
  • Duties include direct care, supervision of studies, behavior, and recreational activities.
  • Mentor individual youth over longer term periods through recreation, tutoring, counseling, according to guidelines set by the shelter and the clients' case worker.
Shelter Manager, to
Burrell Behavioral HealthCity, STATE,
Youth Worker/Tracker, 09/1993 to 07/1995
BcfsCity, STATE,
  • Direct care of juveniles in a group home setting designed to reinforce pro-social behavior.
  • Assigned at least one child at a time to serve as mentor and provide treatment extending beyond day-to-day care provided by facility.
  • Supervisor: Vickie King, Home Manager; John Condron, Social Worker.
Support Trainer, 12/1991 to 07/1995
Doordash, ,
  • Direct care, supervision, and life-skills training of developmentally disabled persons.
  • Documentation of treatment goals, administration of medications, behavior modification were all included in daily routines.
  • Follow and document progress of treatment plan established by QMRP.
Supervisor Platoon Leader, to
Geo Group Inc., ,
Sergeant/Senior Radar Operator, 06/1990 to 09/1994
, ,
  • Responsible for the training, operation, and welfare of a counter-mortar radar and its crew.
Sergeant, 06/1986 to 06/1990
American Red Cross, ,
Regional Program Specialist, 03/2005 to 01/2016
Bannock Youth FoundationCity, STATE,
Developmental Disabilities team supervisor. Responsible of administration of the following programs within Idaho’s Region III: Intensive Behavioral Intervention (IBI). Children’s Service Coordination (CSC), Court-Related Duties, Guardianships, Commitments, Liaison to Idaho State School and Hospital. Includes eligibility determination, treatment plan approval and review, training of providers and agencies, quality assurance of therapy and agencies. Quality assurance surveys of Developmental Disabilities Agencies (DDA) and EPSDT Service Coordination (ESC) agencies providing services to children. This would include file reviews, therapy observations, summary report write up and presenting findings at exit meetings. Responsible for private agencies’ quality assurance and respond to complaints regarding compliance to IDAPA regulations.  Provide expert technical support to families and private agencies. Participate as regional expert in developmental disabilities services in administrative hearings as requested by the Deputy Attorney General’s office. Liaison for the Department for all regional issues involving parents, providers, law enforcement personnel, school districts. Currently involved in the following work groups: a) Idaho State School and Hospital b) Benefit Redesign. Wrote contract and coordinated weeklong training provided by behavior intervention. Provide trainings and presentations to parents and providers.   -          Liaison between Department and parents, provider agencies, law enforcement agencies, and external/internal task forces. -          Supervisor of Regions III administration of the following programs: o    Intensive Behavioral Intervention (IBI) o    Children’s Service Coordination o    Guardianships/court-related duties -          Department representative regarding Federals and state rules and regulations. Particular emphasis on IDAPA. -          Provide technical assistance and clinical guidance on provision of DD services overseen by the Department. -          Audit private agencies for quality assurance and compliance with regulations. Review, approve and monitor agency’s plans of correction. -          Respond to, investigate and follow up on complaints presented to the Department by parents, other providers, or other institution. -          Participate as content matter expert for the Department in due process hearings. Testify in court regarding the  Department’s court-related activities. Supervise staff that respond to court guardianships and placement crises. -          Wrote and monitored contract to provide a $25,000, week-long training provided by the Institute for Applied Behavior Analysis (IABA). -          Periodically conduct presentations to other agencies within the Department, providers, and families regarding parenting education as well as rule or programmatic changes within the Department. -          Developed method of providing IBI tracking by integrating eligibility documents with annual review progress.
Certifications
Intensive Behavioral Intervention (IBI) Idaho State Supreme Court Child Custody Mediator Qualified Mental Retardation Professional (QMRP) EPSDT Service Coordinator (ESC) Crisis Prevention Intervention (CPI)
Education
Graduate: , Expected in 1995
Idaho State University - ,
GPA:
Bachelor's of Science Degree: Psychology, Expected in 1986
graduate of Highland High School - Pocatello, Idaho
GPA:
Psychology

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Resume Overview

School Attended
  • Idaho State University
  • graduate of Highland High School
Job Titles Held:
  • Medicaid Utilization Review Analyst
  • Program Supervisor
  • Analyst
  • Field Program Manager
  • Regional Program Specialist
  • Supervisor
  • Psychosocial Rehabilitation Specialist
  • Job Descriptions
  • Psychosocial Rehabilitation Specialist
  • Psychosocial Rehabilitation Specialist
  • Summer Boyd, Shelter Manager
  • Youth Worker/Tracker
  • Shelter Manager
  • Youth Worker/Tracker
  • Support Trainer
  • Supervisor Platoon Leader
  • Sergeant/Senior Radar Operator
  • Sergeant
  • Regional Program Specialist
Degrees
  • Graduate
  • Bachelor's of Science Degree

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