Utilization Management Resume Sample
Rebekah Wehner
924 Eli Radial,
San Francisco,
CA
+1 (555) 190 7394
Work Experience
Manager, Utilization Management
06/2015
-
PRESENT
Detroit, MI
- Executes periodic competitor utilization management program comparison and analysis to ensure WellCare’s utilization management program maintains competitive edge
- Oversees outside medical services based on Health Plan benefit guidelines and medical necessity
- Assists in developing and maintaining policies and procedures for the Service Area or Medical Center related to Utilization Management
- Hires, trains coaches, disciplines professional and clerical support staff
- Develop staff skills and competencies through training and experience. Available to non-clinical staff as a resource for clinical questions
- Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts
- Provider Networks and Contracting management staff and team
- Benefit Administration (Government Programs Division; State Claims Division; Private - Statewide Division; Private - Regional Division)
- Medical Information Systems
Utilization Management
04/2012
-
12/2014
Philadelphia, PA
- Using good listening skills, conducts calls as indicated, collecting data according to script, tools, and protocols meeting both productivity and performance expectations as identified by unit supervisor/or designee. Conducts all calls in a courteous and customer service friendly manner
- Updates, maintains and/or closes authorizations or tasks for services as assigned within process guidelines
- Processes incoming and outgoing correspondence/faxes in accordance with required standards and within respective timeliness guidelines. Refers episodes to the appropriate clinical team members for review as defined by workflow
- Demonstrates a professional and courteous manner when communicating with others with the ability to clearly and accurately state the agreed upon resolution
- Adhere to company Policies and Procedures, process standards, Standard Operating Procedures and maintains current knowledge of member benefits, rights and responsibilities
- Facilitate annual UM documents (program, work plan, policies/procedures - including medical necessity criteria, and prior year’s evaluation, including measurement of overall UM program effectiveness, using established goals, metric results, and associated benchmarks) and facilitate the adoption of these by appropriate committees
- Licenses/Certifications: Current Pennsylvania state nursing license
Utilization Management Reviewer, Junior
11/2007
-
12/2011
Los Angeles, CA
- All departments within HealthCare Services
- UM Support and Education
- UM Standards and Compliance
- Health Services Research
- Medical Quality Management
- Credentialing and Clinical Risk
- Summarize key past medical history and current support/clinical information to be used as a point of reference for the review process of members
- Supports the daily operations of UM through data entry, interaction with internal and external stakeholders as necessary
Education
University of Phoenix - North Davis Learning Center
2002 - 2007
Bachelor's Degree in Nursing
Professional Skills
- Attention to detail, strong analytical skills; excellent organizational and problem solving skills
- Excellent verbal and written communication skills, including strong customer service skills
- Computer skills including word processing, spreadsheet, and database skills
- Strong skills in the following areas: Oral and written communication, Critical thinking, Organization and time management, and Customer service
- Research, review and respond to general inquiries that demonstrates clear, concise and proficient writing skills
- Strong business writing, presentation and excel skills
- Demonstrated interpersonal, negotiation, and leadership skills
How to write Utilization Management Resume
Utilization Management role is responsible for analytical, training, database, customer, health, organization, finance, integration, security, reporting.
To write great resume for utilization management job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Utilization Management Resume
The section contact information is important in your utilization management resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Utilization Management Resume
The section work experience is an essential part of your utilization management resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous utilization management responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular utilization management position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Utilization Management resume experience can include:
- Verbal and written communication skills, analytical skills
- Relevant clinical work experience - Intermediate Outlook, Basic Word, Excel, PowerPoint, Adobe Acrobat skills
- Relate effectively to physicians, and all levels of the organization in a flexible and adaptive manner
- Manage multiple projects and effectively communicate relevant project information to leadership
- Clinical experience; 2+ year of Case Management and/or Utilization Review experience within a Managed Care organization
- Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care
Education on an Utilization Management Resume
Make sure to make education a priority on your utilization management resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your utilization management experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Utilization Management Resume
When listing skills on your utilization management resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical utilization management skills:
- Solves complex issues within Utilization Management and reports results effectively using evidence-based practice framework
- Demonstrates a high tolerance for ambiguity and change and provides leadership to department staff and others to adapt effectively to meet changing environment
- Budgeting and management skills in acute hospital setting
- Nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment including NCQA experience
- Experience in Health Care Management or any equivalent combination of education and experience
- Proficient analytical, written and oral communication skills
List of Typical Experience For an Utilization Management Resume
1
Experience For Manager, Utilization Management Resume
- Acute care clinical experience; or any combination of education and experience, which would provide an equivalent background
- Advanced verbal and written skills to gather and exchange data with the ability to summarize information to make judgments and influence change
- Direct clinical practice experience hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility
- At least five (5) years of hospital utilization review experience including at the management level
- Experience in a managed care environment or other insurance background
- Clinical experience
- Working with geriatric population or equivalent experience
- Combined Managerial and UM experience in a health plan/Healthcare setting
2
Experience For Director, Utilization Management Resume
- Experience with medically fragile populations required
- Experience in relevant field required
- Utilization management and/or case management experience
- Mentoring employees and supporting ongoing training and development of staff
- Manage client expectations through routine, adhoc meetings, week/monthly reporting and proactively managing client communications
- In collaboration with Human Resources, manages the recruitment, hiring, onboarding and retention of Utilization Management staff
- Responsible for monitoring member and provider satisfaction survey results and creating necessary changes where indicated
- Communicate in writing using proficient grammar
- Thorough knowledge of utilization management and clinical nursing
3
Experience For Manager, Utilization Management Required Resume
- Leads and organizes the ongoing evaluation of the utilization management program against quality and utilization benchmarks and targets
- Provides hands-on support for critical staffing needs
- Utilization management and recent nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetrics and management experience
- Familiarity with Medicare and Medicaid managed care practices and policies, CHIP and SCHIP
- Travel 25% of the month to Maitland
- Authorizations & Referrals Mgmt: Coordinates w/ authorization & referral Mgmt team on outside referrals & coordination of care. Ensure that referrals are entered accurately & timely
4
Experience For Coord, Utilization Management Resume
- Provides overall direction, design, development implementation, & monitoring of utilization programs to meet the Service Area's or Medical Center's utilization goals while maintaining customer satisfaction
- Acts as a resource to the medical staff, administrative staff, divisional, SCPMG, TPMG, & external regulatory agencies in all issues relating to utilization management within the Service Area or Medical Center
- Oversees outside medical services based on Health Plan benefit guidelines & medical necessity
- Analyzes & reports significant utilization trends, patterns, & impact to appropriate departmental & medical staff committees
- Develops, monitors & controls department's budgets
5
Experience For Manager Utilization Management Resume
- Assures compliance w/ Federal, State, JCAHO, NCQA, other regulatory agencies & internal standards & requirements
- Hires, coaches, trains, & disciplines staff to ensure smooth operations in utilization management
- Directs, coordinates and evaluates efficiency and productivity of utilization management functions for physical and behavioral health services
- Works closely with pharmacy and vendors to assure integration, oversight, and efficiency of UM and appeals processes and for delegated functions
- In collaboration with the national clinical team, assures that all utilization management-related activities meet the standards required for the state contract and NCQA
- Identifies opportunities for improvement; organizes and manages cost of care initiatives
- Collaborates with local and national leaders including Quality Improvement, Analytics, Finance, Network, and other areas to assure a comprehensive approach to managing quality of care, service, and cost of care
- Provides expert input to Finance regarding patterns of utilization and cost and high cost cases
- Assures integration and efficiency of Network strategy and vendor relationships with utilization management and claims processes
6
Experience For Utilization Management Director Resume
- Directs the work of Managers, Utilization Management, who assure quality, interrater reliability and standards are met in daily operations
- Develops and enhances program annually
- Analyzes area-specific data to identify trends and opportunities to improve quality of care and/or delivery of services
- Develops and directs innovative utilization management programs/models that improve our membership care costs, care quality, care efficiency, care access and care service
- Directs the day-to-day operations of Utilization Management
- Development of new initiatives
- Coordinates the Medical Management Committee’s activities and interactions with applicable company and UM. Acts as a resource for problem solving with all departments
- Responsible for implementing a UM management program that is structured to meet the needs of the patients and is not overly burdensome for the PCP’s to manage
- Contributes to and supports the corporation’s Utilization and quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts
7
Experience For Utilization Management Reviewer Resume
- Assists nurses in developing contacts and relationships with providers, provider’s office staff and ancillary facilities personnel
- Understands the roles and relationships among medical management (UM, CM, DM), population management, quality initiatives (HEDIS, Stars, CAHPS), and manages the Cognizant solution based on the customers’ specific requirements
- Manages the team to meet and exceed all managerial, HR, financial and operational metrics and service level agreements
- Promote and maintain for the department for all compliance and regulatory requirements
- Manage the department to foster a colloaborative, innovate team to promote a positive work environment
- Collaborate with other key departments within both Cognizant and client environments to deliver end to end solutions and performance
- Oversees UM processes with regards to specialty programs to ensure compliance with Beacon’s policy guidelines, standard operation procedures, external regulatory requirements and URAC/NCQA accreditation standards
- Coordinate efforts with the Member Services and Connections Departments to address members’ and providers’ issues and concerns in compliance with medical management requirements
- Review, revise, and develop policies to ensure consistent practice with regulatory expectations
8
Experience For Director of Utilization Management Resume
- Ensure policies and procedures are available followed within the department
- Ensure training and education on member eligibility and InterQual Criteria to Utilization Review Nurses following Medicare, Medicaid, and Health Choice policies and procedures
- Monitor appropriate and consistent application of InterQual criteria
- Maintain daily operational awareness of department function and take action as needed to ensure optimal operations
- Collaborate with Medical Director to plan and manage daily operations
9
Experience For Utilization Management Clinician Resume
- Maintain inter-rater reliability standards per contractual guidelines
- Review criteria with Medical Services staff and Medical Director(s) at least annually and update as needed
- The Director works collaboratively with the members, providers, health plans, and other departments to maximize member’s benefits within a cost effective environment
- Manage the department to foster a collaborative, innovate team to promote a positive work environment
- NYS RN Licensure required
- Manages the daily operations of Utilization Management, which includes: concurrent and retrospective utilization review for medical necessity, collaboration and participation with the health care delivery team, review of utilization outcomes and related improvement activities
10
Experience For Utilization Management Case Manager Resume
- Participates in departmental cost budgets and cost containment efforts
- Reviews and interprets patient population specific financial reports
- Works independently to resolve issues within Utilization Management
- Utilizes independent judgment to identify opportunities for improvement and coordinate projects to attain goals
- Provides direction and oversight for the UM Specialists and Lead UM specialist(s) daily activities and completes performance evaluations annually
- Hires and implements disciplinary action when needed
- Develops, recommends and initiates corrective action to avoid denials
List of Typical Skills For an Utilization Management Resume
1
Skills For Manager, Utilization Management Resume
- Excellent organizational skills, ability to manage multiple ongoing tasks
- Excellent communication skills. Able to discuss sensitive/ confidential information in a professional, unbiased manner
- Manages, and constantly evaluates staffing levels, assignments, skills, learning needs, and deployment of staff
- Beginning Excel, Word and PowerPoint experience
- Previous progressive management experience including responsibilities for hiring, training, assigning work and managing performance of staff
- Experience in integrating and applying benefit coverage rules and assessing coordination of Benefits guidelines and Managed Care regulation
- Experience in utilization management operations and familiarity with reporting and analyzing managed care utilization data
- Nursing experience in an acute care setting or medical/surgical, pediatrics, or obstetric in a managed care environment
2
Skills For Director, Utilization Management Resume
- Meets health system needs as demonstrated by facility's utilization of resources by timely, accurate and correct billing and payment for services
- Experience with licensing and accreditation standards, regulatory standards, Utilization Review methodology and theory
- Of progressive experience in utilization management and/or healthcare financing
- Experience in data analysis and trending
- Experience with Private Duty Nursing and Personal Care Services
3
Skills For Manager, Utilization Management Required Resume
- Advanced clinical experience in a hospital setting required
- Eight (8) or more year’s healthcare experience including five (5) or more years in utilization review is required
- Medical-Surgical experience
- Experience with Utilization Management / Review
- Experience in a senior management role within managed care / HMO
- Assists facilities to achieve high quality, timely, cost effective, and safe patient care delivery
- Handling escalated and unresolved calls from less experienced team members; ensuring UM Reps are directed to the appropriate resources to resolve issues
- Nursing experience in an acute care setting particularly in medical/surgical, pediatrics, or obstetric in a managed care environment
- Experience in managed care, case management, identifying alternative care options, and discharge planning - Certified Case Manager
4
Skills For Coord, Utilization Management Resume
- Medical Surgical and/or rehab experience required
- Proven team leader with the ability to interact with all levels of staff members and physicians and other healthcare providers
- Manage medical staff dynamics to facilitate effective discussions related to medical activities
- Uphold and demonstrate Highmark's mission and corporate values
- Coordinate the development of the utilization management tools and processes required of an efficient and effective program
- Managed care and Medicaid clinical experience
- Strong problem-solving ability under pressure of timeliness turnaround deadlines
- Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information
5
Skills For Manager Utilization Management Resume
- Ongoing Monitoring, tracking, trending and reporting of Utilization Inpatient and Outpatient Service Patterns
- Developing and adopting best practice methodologies and training programs for utilization management tools and techniques
- Monitoring the timeliness and accuracy of utilization management data and reporting to meet requirements of applicable regulatory agencies
- Using data analysis to identify opportunities for quality improvement
- Assisting to build utilization management initiatives and tools to support Evolent Health and its partners in constant expansion
- Working knowledge of utilization review practices related to regulatory and accreditation requirements
- Enhancing relationships with providers, facilities, plan sponsors, clients, regulatory agencies, and partners
6
Skills For Utilization Management Director Resume
- Depending on line of business: RN
- Working knowledge of multiple clinical areas, financial and data analysis, reimbursement practices, preadmission and concurrent review practices
- Analyzes data and reports metrics for tracking, monitoring, and benchmarking activities associated with the appropriateness of admissions and payment denials
- Development of budgets, staffing plans, and assuring adequate allocation of resources
- Monitor monthly budget for variances, initiating cost savings while maintaining highly efficient operations
7
Skills For Utilization Management Reviewer Resume
- Extensive training class then mentoring with other associate to work through cases and then start to work independently
- Basic to intermediate ease of use with computers and a working understanding of common computer software such as Microsoft Word, Excel and Outlook
- Works closely with network on the training and evaluation of providers as well in resolving provider related issues
- Maintain a focus on the care and service our members receive while exercising fiscal responsibility
- Forge partnerships to ensure a collaborative approach to our members' care, resulting in improved healthcare outcomes
- Promote a work culture that encourages teamwork and rewards exceptional performance while striving for continuous improvement
8
Skills For Director of Utilization Management Resume
- Monitors the accuracy of Utilization Management staff work, and provides education and coaching, when appropriate
- Leadership of utilization management activities including design, and implementation of Utilization Management Program Description goals and related activities
- Responsible for ensuring rigorous, consistent, and disciplined design and execution of integration with the Evolent Health Quality Management program
- Responsible for directing activities related to special projects for utilization management and use of project resources
- Capable of providing in-service education to health care providers on utilization issues based on data outcomes or industry standards
- Monitors appropriate length of stay and ensures patient needs are met while collaborating with payers to facilitate next LOC if appropriate
- Serves as a resource for staff in addressing ethical issues
- Bachelors in Nursing (BSN) required
9
Skills For Utilization Management Clinician Resume
- Completion of an accredited Registered Nursing RN Program required
- Update and maintain utilization management policies and procedures, including program evaluation and reports for internal quality committees
- Knowledge of ancillary services including HHC, SNF, Hospice, etc
- Attends educational meetings/programs to maintain and expand current knowledge regarding managed care and related job responsibilities
- Licensure / Certification: Registered Nursing License
- Function in the role of project leader demonstrating commitment and responsibility to the project’s success
- Delver engaging, informative and well organized presentations
- Develop action plans which promote, support and improve utilization management functions on an ongoing basis
10
Skills For Utilization Management Case Manager Resume
- Productivity goals – 55 case touches per day which is very manageable after training
- Responsible for the oversight of all utilization management activities ensuring consistency of services and achievement of utilization targets
- The Utilization Management clinician (LPN) makes coverage decisions based on specific criteria including Milliman
- Educate and support members/families regarding benefits, eligibility, BCBSMA policies and processes with the goal to empower self-advocacy
- Collaborates with Network leaders to design and operationalize successful methods for working with hospitals, home health, and other services
- Responsible for resolution and communication of utilization management issues and concerns and corrective action plan activities and reporting
- Participates in new systems selection and directs new system testing and implementation for successful utilization management Integration
List of Typical Responsibilities For an Utilization Management Resume
1
Responsibilities For Manager, Utilization Management Resume
- Validates authorization for all procedure / bedded patients UR pre-admission
- Works with the Physician Advisors on process improvement, problem solving and education needs
- Participates in the review and updating of Utilization Management policies
- Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria
- Establishes and communicates estimated LOS using GMLOS or physician specific measurement
- Conducts Level of Care review using electronic system and documents outcomes. Contacts payers as applicable
- Analyzes complex data sets to improve patient quality care/ financial outcomes
2
Responsibilities For Director, Utilization Management Resume
- Assess and identify customer specific and / or population needs to develop a plan of action
- Serve as a subject matter expert to provide explanations and information to others on utilization related issues
- Facilitate care coordination to impact utilization management activity across clinical and multi-disciplinary care teams
- Contribute to audit requests and request for proposals
- Responsible for provider education related to UM processes
3
Responsibilities For Manager, Utilization Management Required Resume
- Lead initiatives as delegated to ensure proper implementation and generate outcome summary and / or report
- Available to non-clinical staff as a resource for clinical questions
- Identify available resources and communicate information to physicians, patients, families and treatment team
- Communicate clinical information externally and internally to patient needs are met
- Consulting and collaborating with providers, members, and other resources as appropriate; assessing, planning, and implementing options and services require to meet an individual’s health needs within the scope of their benefit plan
- Familiarity with UM/CM activities and standardized criteria set
4
Responsibilities For Coord, Utilization Management Resume
- Works independently and collaboratively with the internal and external stakeholders including the Vice President of Health Services, Director of Case Management, Medical Director, and Associate Medical Directors to support implementation of key strategic planning goals
- Participates as an active management member of the Mount Carmel Health Plan representing the Health Services Department in collaboratively meeting operational, budget, and strategic planning goals
- Directs and provides leadership to the Supervisor and other department staff, as well as oversight of all human resources activities including addressing competencies and completing performance appraisals in a timely manner
- Assures compliance with all regulatory requirements related to the area of Utilization Review including Medicare programs required under the regulations
- Prepares and administers department budget related to Utilization Management, if appropriate
- Develops, implements, and communicates effectively with internal and external customers regarding all regulatory requirements, Utilization Review activities and corresponding policies and procedures related to such activities
5
Responsibilities For Manager Utilization Management Resume
- Responsible for development, implementation and management of the annual Utilization Management Plan and all related activities
- Oversees all internal and external orientation and education programs related to Health Services
- Development, implementation, and measurement of department, corporate, and utilization management objectives
- Recruitment, selection, orientation, performance measurement; counseling, and performance improvement planning; promotion and termination per corporate policy; and career development and support of staff
- Constantly evaluate the utilization management markets and incorporate the needs of the healthcare environment into the utilization management programs
6
Responsibilities For Utilization Management Director Resume
- Assure the development of teams which are focused on exceeding the utilization management objectives through team building sessions, team work facilitation, committee opportunities and leadership opportunities
- Develop and coordinate cross-functional/interdepartmental relationships which enhance the overall care delivery and outcomes for our customers
- Assist in the analysis of clinical data elements and present data analysis to a wide range of audiances
- Assure implementation and measurement of high performance standards
- Provide direct reports with guidance and educational tools in order to assure compliance with a minimal individual audit score that meets department standards
- In collaboration with other units and divisions, establish guidelines that quantify measurable utilization management value, benefit, and outcomes
7
Responsibilities For Utilization Management Reviewer Resume
- Coordinate and implement processes which require and enhance direct report accountability
- Describe and document outcomes in the Program Description for presentation at the Care Management Committee
- Daily accountability for triage, crisis intervention and referral activities
- Identify, develop, and implement division/department projects focused on quality, utilization, process and/or outcome improvements
- Identify industry benchmarks through scientific research to assure operations exceed industry standards
8
Responsibilities For Director of Utilization Management Resume
- Represent the department by participation throughout the corporation on projects and committees
- Develop and implement processes which assure 24-hour availability of utilization management expertise
- Develop and implement action plans designed to achieve and enhance compliance to accreditation standards in accordance with NCQA, URAC, CMS, DOH, and DOL regulations
- Work in concert with all corporate divisions and departments to develop strategies supportive of the corporate mission and vision
- Assist in coordination and management of the pre-determination process of medical and dental services
- Assist in the development of integrated service delivery to members and oversee utilization management data and processes to maintain industry standards and practices
9
Responsibilities For Utilization Management Clinician Resume
- Maintain all utilization management reporting
- Interact with providers and staff to manage benefits aligned with ODJFS regulations, URAC regulations and CareSource policies and vision
- Regularly report all utilization management regulatory requirements
- Develop, implement, and measure department, corporate, and utilization management objectives
- Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity per corporate policy
- Ensure the development of teams which are focused on exceeding the utilization management objectives through team building sessions, team work facilitation, committee opportunities and leadership opportunities
10
Responsibilities For Utilization Management Case Manager Resume
- In the Insurance or related industry
- Active United States Registered Nurse (RN) license
- Functions as a Utilization Management subject matter expert
- Develops daily assignment of UM staff to units/coverage areas and ensures completion of admission and concurrent reviews
- Assists UM Director by monitoring the daily operational management and resolution of denials; keeps UM Director informed of identified denial trends; assists UM Director in the management of denials by collaborating with the PRMO and Payor relations to mitigate and resolve denials
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