Candidate Information Name Available: Register for Free Title Case Management Utilization Target Location US-CO-Centennial Phone Available with paid plan	20,000+ Fresh Resumes Monthly     View Phone Numbers     Receive Resume E-mail Alerts     Post Jobs Free     Link your Free Jobs Page     ... and much more Register on Jobvertise Free
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Candidate's Name ,Street Address  South Elm Ct.Centennial, CO Street Address
PHONE NUMBER AVAILABLEOBJECTIVEServe in a peer or supervisory role working remotely with a multi-functional team of health professionals and stakeholders performing all aspects of utilization management and complex case management. Collaborate and adjudicate all denials, appeals and grievances with medical staff and all stakeholders in a virtual environment.Work as a resource to staff members and other participants based upon 14 years of experience performing prospective, concurrent, retrospective reviews, and appeals and grievances. Analyze and project medical loss ratio for patients with complex care needs. Provide summary of medically based thorough and complete evaluations including prospective considerations of care, costs, and revenue cycles.QUALIFICATION SUMMARYHospital clinical nursing experience, including ED and Med-SurgHealth plan and provider-side experience performing and assigning on-site and remote utilization management projectsCertified InterQual instructorWorked collaboratively with providers, IPAs, QIO, and health plans in gaining an expertise of all aspects of managed care operationsAdvocacy of patients or target population to assure excellence of care was being provided to all in the most appropriate level of care settingsExperience, knowledge and understanding of all universally accepted medical necessity criteria including: plan-specific criteria; LDC/NDC, CMS, M&G, and InterQualExperienced with the nuances and attention required in the administration of benefits and care for special needs, dual eligible, diverse populations and complex case management patientsCritical thinking and problem-skillsComfortable and competent in working with cross-functional teamsProficient at DRG validationThorough understanding of the concepts of risk-sharing; delegation; HIPAA and HEDIS.Strong leader and team playerCognizant and supportive of Corporate financial goalsPatient AdvocacyRemote Xfinity high speed internet (10Gbps)EXPERIENCE2017-2022 Anthem of Colorado (Work at Home)Reviewed records/EMRs of members with participating PCPs in the application of NCQA Quality measures to assist in the determination of STAR ratings for the physician/IPA with the health plan.Documented review results into software system for compilation of overall STAR ratings.Educated physician networks using best practices to improve performance and scores.1999-2017 New West Physicians (OPTUM)(As described in QUAILIFICATION SUMMARY)EDUCATIONSt. Joseph School of Nursing-Diploma ProgramLICENSES and CERTIFICATIONSColorado Board of Nursing- Active and non-restricted / compact RN license #0043106Certified InterQual Instructor