Driven and efficient registered nurse director with over 18 years utilization management, disease management, revenue cycle, appellate leadership experience.
Responsible direct and indirect reports ranging from local to national oversight ranging from 1-50 multidisciplinary team members including utilization management nurse/ therapists reviewers.
Directed all aspects of utilization management, care coordination, utilization compliance, authorizations and referrals, and discharge planning throughout various industry settings.
Facilitated all levels of staff functioned within timeliness and appropriateness of case reviews and directed team efforts to optimize appropriate length of stays, quality care/ disease management and discharage planning; both remotely and on site during audits, utilization rounds for timely, appropriate medical treatment. Taught all levels of clinical staff to evaluate plans of care, care coordination/ administration of medical treatment documentation per payer, state, federal guidelines.
Directed the supervision of daily operations of the utilization management (UM) departments, multidisciplinary staff, ensure appropriate usage of resources in order to facilitate the UM processes while within compliance of applicable state program guidelines, policies and procedures and analyze/recommend enhancements. Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements.
Lead teams to perform analysis for process improvement areas that were identified and corrective plans of action necessary to facilitate department functions changes/ corrections.
Educate all levels to ensure consistent performance and adhere to standards, senior direct reports with findings, corrective action plans and assist with and facilitating system processes for implementation. Directed coordination with providers, partners, vendors, and subcontractors as necessary.
