Valence Health - Supervisor UM Resume Example

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Zoey Brooks
XXX XX XXXXX XXX, Palatine, IL 60067
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Ph: XXXXX XXXXXXXX
Summary

Seasoned Certified Case Manager with more than 6 years of experience in fast paced telephonic environment of UM/CM. Proven leader with experience in supervising 40 staff members. Autonomous and self starting with successful telecommuting experience. 

Skills
  • Experienced in UM with expertise in Medicare and familiar with CMS regulations.
  • CCM with experience supervising 40 UM and CM employees.
  • Excells at teaching CM's to be more thorough and dynamic. 
  • Proficient in technology with excellent typing skills and experience in multiple software programs.
  • Familiar with Interqual and Milliman guidelines.
  • Proven success record in Humana and BCBS audit preparation.
Experience
Supervisor UM/CM, Apr 2015Present Valence Health, Chicago, IL Supervisor with about 40 direct reports including UM RN's and LPN's, CM's, UM Technicians, and Outreach Coordinators. Responsible for daily operations, ensuring that authorizations are completed within TAT. Works to resolve staff, member and provider issues. Handles all timecards and PTO requests. Completes performance evaluations. Does quarterly and client audits of all UM and CM nurses. Provides education and feedback to nurses to improve their skills and performance. For CM's provide education focusing on developing dynamic care plans and increasing member engagement. Promoted to Manager of CM in October but has not transitioned into that role due to staffing shortages in UM. 
Supervisor, UM/CM, Mar 2014Apr 2015 NAMM - United Health Group, Hillside, IL
  • Supervisor Case Management/Utilization Management Direct supervisor for the CM/UM team, consisting of eight nurses and two support staff and serving 7 commercial and Medicare IPA's.
  • Internally promoted to supervisor position after 6 months as a Utilization Manager for a Medicare replacement IPA.
  • Supervisor responsibilities included coordinating staff schedules, interviewing and hiring for UM and CM positions, delegating responsibilities to team members, reviewing utilization cases and complex case management cases to ensure quality and productivity.
  • Additional supervisor responsibilities included preparation and presentation of UM statistics and complex case detail for all 7 IPA's, as well as ongoing, direct communication with the Medical Directors for each IPA.
  • Also coordinated projects with supervisory staff of other departments to ensure quality and integrity of reporting.
  • Provided training and ongoing support for all staff.
  • Coordinated all health plan audit preparation, and passed Humana's UM audit with a score of 98%. 
Nurse Case Manager, Apr 2012Mar 2014 Swedish Covenant Hospital, Chicago, IL
  • Responsible for complex case management and utilization review for a Medicare Advantage HMO.
  • Case management/utilization management responsibilities include obtaining and reviewing clinical documentation from hospital case management staff or EMR; determining appropriateness of care per Interqual guidelines, and issuing authorizations for care or communicating with physicians for additional treatment plan.
  • Additional responsibilities include coordination of care and discharge planning, including home health, DME, skilled care or rehab.
  • Complex case management including regular telephone contact and at times home visits for members; coordinating in home services to help assure health and safety of members; disease management for patients with co-morbidities, such as CHF, CAD and DM.
  • Prepared HEDIS and quality studies. 
Nurse Case Manager, Oct 2009Apr 2012 NAMM-IL, Hillside, IL
  • Responsible for complex case management and utilization review for a Medicare Advantage HMO.
  • Case management responsibilities include obtaining and reviewing clinical documentation from hospital case management staff or EMR; determining appropriateness of care per Milliman guidelines, and issuing authorizations for care or communicating with physicians for additional treatment plan.
  • Additional responsibilities include coordination of care and discharge planning, including home health, DME, skilled care or rehab.
  • Complex case management including regular telephone contact and at times home visits for members; coordinating in home services to help assure health and safety of members; disease management for patients with co-morbidities, such as CHF, CAD and DM.
Telephonic Case Manager, Aug 2007Aug 2009 CorVel Corporation, Downers Grove, IL
  • Responsible for case managing 60-75 workers compensation files.
  • Case management responsibilities included reviewing medical treatment for medical appropriateness and necessity; maintaining consistent professional contact with injured employees; coordinating multi-disciplinary medical services with physician offices, therapy facilities and DME companies.
  • Additional responsibilities included follow up with treating providers for appropriate treatment plan and work status; notifying insurance adjusters with appropriate recommendations regarding direction and plan for worker's compensation files including recommending independent medical examinations and utilization review.
Enrollment Nurse Specialist, Nov 2004Mar 2006 Focused Health Solutions, Deerfield, IL
  • Responsible for receiving and responding to calls for enrollment into disease management program, including those calls from Worked effectively and efficiently in a busy call center.
  • Completed detailed telephonic assessments including health and medication histories.
  • Used assessment data to prioritize diseases in order to assign enrollee to the appropriate case management department (i.e.
  • Diabetes, CHF, Back and Neck Pain, HTN, CAD, etc.)Additional responsibilities included assisting case managers with semi-annual and annual outbound calls and collecting assessment date to determine continued eligibility for the program.
Home Health Nurse, Jan 2003Jan 2004 Family Home Health, Addison, IL
  • Responsible for direct patient care, maintaining ongoing relationships with patients, and conducting initial and ongoing assessments.
  • Collaborated with physicians, therapists, laboratory personnel, social workers, family members, and guardians in order to provide the best possible care, as well as maintain patient's privacy and dignity.
  • Instructed patients and family members in wound care, disease and medication management and infection control.
  • Performed phlebotomy and followed through with laboratories, physicians and patients.
  • Completed all required documentation in a timely and organized manner and in compliance with HIPPA regulations.
Case Manager, Aug 2001Nov 2003 AABCOR, INC, Darien, IL
  • Responsible for home visitations and telephonic case management of up to forty brain injured clients.
  • Conducted initial and periodic in home assessments including health assessment and medication histories, and economic assessments for eligibility purposes.
  • Worked in an office setting, contacting clients by telephone in between home visits.
  • Determined various socioeconomic needs of brain-injured clients.
  • Placed homemaker services within the home and collaborated with other members of the healthcare and social services team to insure client safety and independence.
Staff Nurse, Oct 1999Jul 2001 Illinois Masonic Medical Center, Chicago, IL
  • Team member generating favorable patient outcomes and maintaining rapport with all members of the interdisciplinary staff.
  • Provided patient assessment, planning, implementation and evaluation at all levels of care, from admission to discharge.
  • Provided prescribed treatments including would care, IV starts and phlebotomy.
  • Provided teaching to patients and family members related to disease management, medications, wound, ostomy, trach, and foley care, and infection control.
  • Worked to patient privacy and dignity in accordance with HIPPA.
  • Rotated charge nurse duties with fellow nurses, and completed bed assignments.
Education
Associates of Applied Science, Nursing Truman College, Chicago, IL

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About this resume

Supervisor UM FROM Palatine , Illinois RESUME

This is a resume for a Supervisor UM in Palatine, Illinois with experience working for such companies as Valence Health and NAMM United Health Group. The grade for this resume is 0 and is one of hundreds of Supervisor UM resumes available on our site for free. Use these resumes as templates to get help creating the best Supervisor UM resume.

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School Attended
Truman College