Utilization Management Specialist Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • H: (555) 432-1000
  • C:
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary
Registered nurse with more than 30 years of clinical experience and several years of management experience with strong background in patient record reviews with emphasis on medical necessity as outlined by Medicare, Medicaid and managed care companies.
  • Knowledge of Medicare and Florida Medicaid regulations.
  • Work well independently.
  • Proficient computer skills.
  • Time management skills.
  • Independent judgment, creative thinking and decision making.
  • Attention to detail.
Work History
Utilization Management Specialist, 08/2014 to Current
Adventist Health System Beaver, PA,
  • Continually improved knowledge, skills and performance based on feedback and self-identified professional developmental needs.
  • Closely collaborated with management team to make necessary improvements.
  • Assisted in creation of department policies and procedures.
  • Acted as mentor and resource to staff including new hires.
  • Assisted director in day-to-day management activities.
  • Utilized Interqual criteria to review admitted patients for appropriate status placement and concurrent medical necessity based on Medicare and Medicaid guidelines.
  • Collaborated with onsite Clinical Effectiveness team regarding patient’s discharge readiness.
  • Submit requests for authorizations for Florida Medicaid recipients, including appeal of denials.

Utilization Management Supervisor, 06/2010 to 08/2014
Capital Health Newtown, PA,
  • Recruited, hired, trained and coached employees.
  • Developed a system of staff communication.
  • Interpreted and communicated new or revised policies to staff.
  • Achieved high staff morale and retention through effective communication, prompt problem resolution, proactive supervisory practices and facilitating a proactive work environment.
  • Monitored and evaluated staff productivity.
  • Identified process improvements in the day-to-day functioning of the department.
  • Closely collaborated with management team to make necessary improvements and satisfy department needs.
  • Established staff schedules and assignments based on department needs.
  • Maintained good communication between department heads, medical staff and administration by attending meetings and synchronizing interdepartmental functions.
  • Cooperated and communicated effectively with physicians and their staff to ensure client satisfaction and compliance with set standards.
  • Served on Appeals Committee. Reviewed requests for denial appeals, reviewed records and compiled summary of information for use by Appeals Committee.
Utilization Management Specialist, 04/2009 to 06/2010
Allina Health Systems Albertville, AL,
  • Reviewed criteria for authorizations, admission and eligibility of benefits for members of Memorial Managed Care Plan and Primary Care.
  • Worked closely with medical directors in review of cases for medical necessity and benefit coverage.
  • Assisted in training new employees.
  • Functioned as a resource to other departments and providers.
  • Assisted in creation of a newsletter for pregnant SFCCN (Medicaid) members.
  • Participated in Employee Activity Committee.
Admitting Nurse, Current to Current
Liberty Hospital Kansas City, MO,
  • Organized the department in accordance with administrative guidelines in order to provide specified nursing services to meet the legal, organizational and medical staff guidelines.
  • Utilizing Interqual criteria, reviewed patients' charts for appropriate admitting status.
  • Worked in conjunction with case managers for ongoing, concurrent review.
  • Coordinated requests for international transfers to Memorial Regional Hospital.
  • Created a resource book for use by staff.
Associate of Science: Nursing, Expected in 1977
Miami-Dade Community College - Miami, Florida

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School Attended
  • Miami-Dade Community College
Job Titles Held:
  • Utilization Management Specialist
  • Utilization Management Supervisor
  • Utilization Management Specialist
  • Admitting Nurse
  • Associate of Science

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