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Click here or scroll down to respond to this candidateCandidate's Name , CSWStreet Address Bay Tree WayLouisville, KY Street Address
PHONE NUMBER AVAILABLE HomePHONE NUMBER AVAILABLE CellEMAIL AVAILABLECAREER OBJECTIVEA challenging position, which requires motivation, dedication, and where individual achievements and performance will be recognized allowing opportunities for growth and development. PROFESSIONAL EXPERIENCEWellcare Health Plans Nov 2017-Present Hrs 8am-5pmClinical Social Worker Participates in and supports developed care plans for members with high level acuity needs utilizing social service expertise to evaluate the members need for alternative services and third party needs. Outreaches to members telephonically and/or in-person and coordinates member's case management services. Interacts continuously with members, family, physician(s), and other resources to determine appropriate behavioral action needed to address/support medical needs. Reviews benefits options, researches community resources, coordinates services, trains/creates behavioral routines and enables members to be active participants in their own healthcare. Provides telephone follow-up to ensure members have seen their PCP and are completing their treatment plan or preventive care services a defined by the PCP or guidelines. Coordinates community resources with emphasis on the development of natural support system. Coordinates benefits, regulations, laws and public entitlement programs. Acts as a liaison and member advocate between the member/family, physician and facilities/agencies. Assists in obtaining benefits for members through community resources when benefits are exhausted or not available. May manage members with severe mental illness who have high rates of behavioral health utilization and/or severe psychosocial vulnerability. Acts as team SME in order to achieve optimal clinical and resource outcomes. Carewise Health Jan 2016- Nov 20179.30am-6pmUtilization Reviewer Responsible for the telephonic and fax delivery, of the Utilization Management process to include: assessing, planning, implementing and, coordinating clinical recommendations regarding medical necessity for admission, continued stay and the development / implementation of a basic case management treatment plan. Collects in-depth information regarding a patients clinical history, prognosis, treatment plan, response to treatment, access to care, access to personal and community resources, utilization of care, personal coping mechanisms, learning needs and financial constraints. Determine specific short and long-term goals, objectives, and interventions with accompanying timeframes. Coordinate quality healthcare services overseeing clinical services provided by homecare vendors or sub-acute facilities, customer service, and competitive pricing. Will conduct an on-going assessment of case and make plan modifications, as necessary, to achieve patient goals and improve outcomes. Screens for cases which do not meet the client specific guidelines, i.e. physician developed criteria, Medicare and/or Medicaid guidelines and refers them to the Medical Panel accordingly. Establishes a quality check date using client specific guidelines. Utilizes nursing experience and judgment in addition to the client specific guidelines when determining medical necessity and quality check dates. Performs multiple tasks within the review process including knowledge of different systems, reviewing for multiple clients and the ability to interpret and apply multiple benefit configurations to the review process. Monitors daily work flow queues and performs necessary calls to ensure completion of reviews according to department procedure and URAC guidelines.-Responsible for maintaining expected standards developed by the quality/accreditation and compliance department. Perform discharge planning for the member if necessary and allowed by client contract..Our Lady of Peace Apr 2014-Dec 2015 11.30pm-8amAssessment Clinician Evaluate individuals seeking psychiatric and substance abuse treatment. Determine provisional diagnosis and discuss treatment recommendations with patients, family, medical providers. Develops relationships with community partners by consistently providing world-class service. Conduct insurance pre-certifications for individuals evaluated. Demonstrate proficiency and skills in providing access to optimal level of care, valid referrals based on clinical assessments and providing patient and families with accurate and relevant information relating to programs, treatment, and patient right issues. Demonstrate effective understanding of legal issues associated with assessments/admissions for voluntary/involuntary and mental inquest warrant processes. Uspiritus-Brooklawn _July 2013-Jan 2014_ 9am-6pmTherapist Demonstrated clinical knowledge of assigned population Responsibility of doing individual, group, and family therapy using a variation of modalities. Responsible for continuity of care involving clients. These include appropriate referrals and evaluations as deemed necessary. Interact with various agencies to determine levels of service and care that is clinically necessary Experience with population from ages 12-17 yrs old in a residential setting. Worked with children with special education and behavioral issues. Represent the interest of the children on caseload by attending school meetings, case management, and other meeting as deemed necessary. Development of Treatment plans.East End Counseling Dec 2003-Present6pm-8.30pmSat 9am-12pmClinical Therapist /Private Practice (I still do part-time work) Duties include individual, group, and family therapy to assigned populations. Conduct domestic violence, anger management, substance abuse and mental health assessments of court ordered individuals. Specializing in brief therapy while utilizing various therapeutic interventions. Responsible for continuity of care involving clients. These include appropriate referrals and evaluations as deemed necessary. Interact with various agencies to determine levels of service and care that are clinically necessary. Conduct psych/social assessments with clients that suffer from mental health disorders such as bi-polar, PTSD, and other serious mental health issues. Maintain appropriate documentation as it relates to treatment planning. Led contractual work with inmate population at Louisville Metro Corrections from 2006 to 2013 Humana Inc, Nov 2004- June 2013 8.30am-5pmProject Analyst_Frontline LeaderContract AnalystLearning FacilitatorPolicy ConsultantClaims Adjuster Claims Adjuster: Responsibilities include processing various claims on the EDI Metavance Platform. Assist with various training needs. Participate on various projects that require high motivation and knowledge in order to perform and attain maximum quality and consistency within claim operations. Designated as a subject matter expert. Policy Consultant: Documenting policy and procedure as it pertains to claim processes. Participate in meetings that were information specific to the creation and updating of documents. Providing consultation that enhances process functions. Trainer: Plan, conduct, and coordinate operational training in the following areas: Claims (Metavance)(CIS) Contract Information Systems. Contact Analyst: Provide leadership and guidance through several processes that include claim operations, contract knowledge, reimbursement methodology consultation regarding high dollar processes and other functionalities of the business. Participate on various project teams using Six Sigma and Project Methodology to ensure cost savings, process improvements, and other functionalities vital to the organizations success. Acted as interim supervisor when manager was absent. Operations Supervisor/Frontline Leader: Assist, plan, and coordinate various management and training activities within PPNO (Provider Process and Network Operations) which consist of provider resolution, contract interpretation, and consultation with other areas that include Service Operations, Customer Service, and Claims Rework. Assist provider contractors with payment methodologies to ensure positive provider relationships. Coordinate various training opportunities to ensure staff is current with processes that enhance job performance. Effectively develop partnerships throughout the organization in order to support departmental and organizational business needs. Demonstrates the ability to achieve results, outperform the competition, and win through continuous upgrading of one's own and other's work performance. Responsible for the daily supervision of up to 19 people at any given moment. Maintain inventory, making sure work is distributed appropriately Attend Management meetings, providing positive feedback to associates. Responsible for Departmental training needs thru assessments and interventions as necessary. Act as Liaison for communicating process issues as they pertain to provider contracts. Assist projects writers with difficult claim pulls based on extensive contract and payment methodology. LifeSpring Mental Health Services Dec 2001-Dec 2003 8.30am-5.30pmClinical Therapist Duties included conducting individual, group, and family therapy to population that may been diagnosed with mental illness and substance abuse (dual diagnosis). Also worked with children ages 8 to 17 with emotional and behavioral difficulties. Responsible for discharge, and treatment planning. Worked closely with various agencies that include child protection, legal entities and other community representatives. Performed mental status exams for social security, Medicaid and Medicare to determine outcome of benefits. Conducted psych/social assessments with clients that suffer from mental health disorders such as bi- polar, PTSD, and other serious mental health issues. EDUCATIONBachelor of Science- Major-Sociology-University of Louisville August 1998 Masters of Science in Social Work- University of Louisville. May 2001 TRAININGS AND CERTIFICATIONSState Certified Autonomous Batterer Intervention Provider (Bip) Certified Social Worker (CSW) currently under supervison for LCSW Certified DUI AssessorSKILLSProficient in Microsoft Word, Excel, PowerPoint, Lotus Notes, Internet Explorer, Novell software, Windows NT, and Windows 95,98,Millennium and XP, Vista, and 7 |
