| | | 20,000+ Fresh Resumes Monthly | |
|
|
| |
Click here or scroll down to respond to this candidateCandidate's Name
Street Address Willott Square Dr.St. Peters, MO Street Address
PHONE NUMBER AVAILABLE EMAIL AVAILABLEPROFESSIONAL SUMMARYHighly skilled Clinical Program Manager with over 14 years of experience in behavioral health, case management, and utilization management. Proven ability to lead interdisciplinary teams, develop and implement clinical programs, and ensure compliance with NCQA, and other regulatory standards. Seeking to leverage expertise in utilization review, care coordination, and medical necessity determination to drive quality care, cost-effective solutions, and improve healthcare outcomes.Proficient in Microsoft Office Suite (Word, Excel, PowerPoint), EMR/EHR systems (e.g., Epic, Cerner), and skilled in data analysis, compliance auditing, and report generation. Strong client management and customer service skills. Licensed Professional Counselor (LPC) with a Class E Drivers License.SKILLS Utilization Management (UM) Program Development & Implementation Clinical Supervision & Staff Training Data Analysis & Reporting Regulatory Compliance (HIPAA, NCQA, CMS) Medical Necessity Determination Care Coordination & Discharge Planning Interdisciplinary Collaboration Healthcare Quality Improvement Behavioral Health Care Advocacy EMR/EHR Systems (Epic, Cerner) Utilization Review (UR) Processes Patient-Centered Care Behavioral Health Programs Multidisciplinary Team Collaboration Benefit Coordination Patient Advocacy Mental Health Parity Compliance Case Management Crisis Intervention Licensed Professional Counselor (LPC) - Missouri PROFESSIONALHeres a version of your responsibilities as Clinical Program Manager Behavioral Health Utilization Management, optimized for ATS with relevant keywords and key skills: Clinical Program Manager Behavioral Health Utilization Management United Health Group - Optum St. Louis, MO September 2022 Present Lead and manage a team of clinicians, case managers, and support staff in delivering behavioral health utilization management services, ensuring effective resource utilization and quality care delivery. Develop, implement, and monitor clinical programs, ensuring alignment with NCQA, CMS guidelines, and industry standards to meet the needs of clients and ensure compliance with state and federal regulations. Oversee the utilization review (UR) process, including prior authorization, concurrent review, and retrospective review, ensuring services are medically necessary, cost-effective, and compliant with evidence-based guidelines (e.g., MCG, InterQual). Collaborate with healthcare providers, insurance payers, and other stakeholders to enhance care coordination, improve patient outcomes, and manage healthcare costs through effective communication and contract compliance. Analyze data and key performance indicators (KPIs) to monitor program performance, identify trends, and implement continuous improvement strategies aimed at enhancing clinical outcomes and achieving cost savings. Conduct staff training, clinical supervision, and professional development, enhancing team competency in utilization management, clinical documentation, and care coordination protocols. Ensure compliance with HIPAA, accreditation standards (NCQA, URAC), and organizational policies to maintain regulatory compliance and ensure quality management practices. Manage utilization review processes, ensuring clinical services are appropriate, medically necessary, and adhere to clinical guidelines while promoting patient-centered care and cost containment. Collaborate with multidisciplinary teams including physicians, nurses, and social workers to develop and implement individualized care plans aimed at optimizing patient outcomes and minimizing healthcare costs. Provide education and guidance to clinical staff on utilization management best practices, protocols, and healthcare regulations, fostering a culture of clinical excellence.United Health Group - Optum St. Louis, MOSenior Behavioral Health Care AdvocateMay 2017 September 2022Heres an optimized version of your responsibilities as a Team Lead, tailored for ATS with relevant keywords and key skills:Team Lead Behavioral Health Care ManagementUnited Health Group - Optum St. Louis, MO Assisted in leading a team in performing care management activities to ensure that patients moved efficiently and safely through the continuum of care, from admission to discharge and post-discharge follow-up. Conducted clinical assessments and motivational interviewing to ensuring patients received the right care at the right time. Evaluated the need for additional clinical services, identifying gaps in care and advocating for necessary services to improve health outcomes and support cost-effective care delivery. Coordinated benefit administration and care transitions across various levels of care, including inpatient, outpatient, and community-based services, ensuring seamless continuity of care. Collaborated with facility staff to develop and enhance treatment plans, identifying opportunities to add value and improve the effectiveness of interventions. Identified and coordinated community-based services for discharge planning, ensuring that patients had access to appropriate follow-up care and reducing the risk of readmissions. Managed and administered behavioral health benefits, ensuring compliance with mental health parity laws and utilization review guidelines. Assisted with the development and refinement of individualized treatment plans, aligning with clinical guidelines and patient needs. Maintained accurate documentation of all care management activities in accordance with regulatory standards (e.g., HIPAA, NCQA) and organizational policies.BJC Behavioral Health St. Louis, MOEducational Support CounselorApril 2014 May 2017 Established collaborative relationships with school districts, behavioral health agencies, and law enforcement to ensure students received appropriate care in the least restrictive environments. Provided individual and group therapy, crisis intervention, and intake assessments for students with mental health and developmental concerns using evidence-based practices such as Cognitive Behavioral Therapy (CBT) and Trauma-Informed Care. Delivered mental health education, consultations, and outreach to school faculty and students, focusing on prevention and early intervention. Coordinated with families to ensure proper referrals to psychiatric, psychosocial, and medical services for long-term support. Maintained accurate documentation in compliance with state guidelines and behavioral health regulations.Crider Health Center Wentzville, MOAdult Community Support SpecialistAugust 2010 April 2014 Utilized advanced clinical skills to engage high-risk clients in behavioral health crisis services, shifting their focus toward health and wellness. Managed care transitions from inpatient to community-based services, reducing readmissions and improving continuity of care. Conducted therapeutic individual and family sessions focused on substance abuse recovery, co-occurring disorders, and chronic mental health conditions. Developed individualized treatment plans and implemented strategies to prevent future crises. Participated in interdisciplinary case reviews and treatment planning discussions to ensure comprehensive care coordination Complied with regulatory standards and maintained documentation in line with behavioral health industry guidelines.EDUCATIONLindenwood University St. Charles, MOMaster of Arts in Professional CounselingGPA: 3.8Graduated: May 2010Southeast Missouri State University Cape Girardeau, MO Bachelor of Science in EducationGPA: 3.1Graduated: December 1994LICENSE AND CERTIFICATIONS Licensed Professional Counselor (LPC) State of Missouri issued 2014 HIPAA Compliance Training Cultural Competency Certification |
