Utilization Management Clinical Health Supervisor - Healthcare Resume
Utilization Management Clinical Health Supervisor - Healthcare Resume
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Utilization Management Clinical Health Supervisor Resume


Desired Industry: Healthcare SpiderID: 79806
Desired Job Location: Hanover Park, Illinois Date Posted: 8/24/2017
Type of Position: Full-Time Permanent Availability Date: Immediately
Desired Wage: 85000
U.S. Work Authorization: Yes
Job Level: Management (Manager, Director) Willing to Travel:
Highest Degree Attained: Other Willing to Relocate: Yes


Objective:

Performance-focused and highly organized professional, offering comprehensive experience in managing a wide array of clinical health services relating to the high risk OB/NICU member population. Effective at identifying and meeting member needs, while successfully developing and streamlining programs in the hospital setting. Proactive utilization clinical consultant; experienced in clinical interpretation, and equipped with well-defined communication, problem-solving, technical, and multitasking skills. Proficient with true concurrent review as well as DRG.


Experience:


Professional Experience

Aetna Better Health of Illinois | Chicago, IL (2015–Present)
Clinical Health Supervisor Dec 2016–Present
Supervise the high-risk OB Neonatal Intensive Care Members in charge of working on the utilization management (UM) and case management (CM) of high-risk pregnancy and NICU-related members
Provide expert leadership to a team of four nurses in ensuring the completion of cases within the required turnaround time; while acting as resource to the HROB/NICU Team and other departments regarding obstetric and pediatric cases
Preside over weekly team meetings and weekly medical director rounds, while assigning case management to high-risk OB/NICU members
Assume full accountability in conducting audits, facilitating team meetings, updating key process, working closely with providers, as well as serving as resource in all medical and NICU concerns
Guarantee smooth operations of UM and CM departments in close coordination with all other departments
Highlights:
Successfully established and streamlined guidelines for the Maternity NICU’s Team process
Earned nomination for a silver award for implementing the institution’s mission and values
Played significant roles as team lead and interim supervisor upon leave of the previous supervisor for the HROB/NICU Team

Utilization Management (UM) Clinical Consultant Case Manager - Registered Nurse Apr 2015–Dec 2016
Rendered assistance to the director and manager on Healthcare Effectiveness Data and Information Set (HEDIS) as well as on the request for proposal (RFP) questionnaire
Assessed all incoming clinical reports in compliance with the Milliman Care Guidelines to identify admission and continued inpatient stay
Coordinated with Medical Directors and other staff members in overseeing the plan for continued medical stay
Solely maintained daily operations of UM and CM work in adherence to process and workflow
Proactively provided emotional support, education, and guidance to new mothers and high-risk obstetric patients
Efficiently assisted hospital discharge planners in meeting discharge needs

St. Alexius Medical Center, Alexian Brothers Women & Children's Hospital | Hoffman Estates, IL
Registered Nurse - International Board Certified Lactation Consultant Jun 1985–Apr 2015
Rendered quality nursing care to critically ill and premature infants, while creating and executing individualized care plans
Worked closely with the Medical Team in daily management functions while participating at daily medical rounds
Facilitated weekly multidisciplinary planning meeting while analyzing patients’ discharge needs, arranging appointments, and educating families
Monitored strict adherence to a wide array of guidelines including Joint Commission, Health Insurance Portability and Accountability Act (HIPAA), Illinois Department of Public Health (IDPH), and American Academy of Pediatrics (AAP)
Highlights:
Successfully developed and implemented the following programs:
NICU-based lactation program providing optimal outcomes in nutrition and education as well as acting as staff, physician and patient resource; and
A NICU-based discharge planning program


Education:

Education and Credentials

Associate’s Degree in Nursing | William Rainey Harper College, Palatine, IL

International Board Certified Lactation Consultant (IBCLC): 1997–Present
Cardiopulmonary Resuscitation (CPR) Certification, Valid Until Sep 2018
Neonatal Resuscitation Program (NRP) Certification, Valid Until Sep 2018



Professional Development

QNXT and Dynamo Computer Charting Systems | Aetna Better Health of Illinois | Chicago, IL


Affiliations:
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Skills:


Core Competencies

Utilization Management
Quality Patient Care
Medical and Regulatory Compliance
Strategic Planning and Assessment
Case Management
Staff Supervision and Assistance
Continuous Process Improvements
Organizational Leadership and Team Building


Additional Information:

Activities

Nurse: 2011 | March of Dimes



Technical Acumen

Microsoft Office Suite (Word, PowerPoint, Outlook, and Excel)
QNXT | CareWeb Qi | Dynamo Software | Internet Applications


Reference:
Available upon request.


Candidate Contact Information:
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