Medical Management Resume Samples
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Medical Management Resume Samples
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DT
D Tromp
Daron
Tromp
9387 Mueller Knoll
New York
NY
+1 (555) 437 1796
9387 Mueller Knoll
New York
NY
Phone
p
+1 (555) 437 1796
Experience
Experience
Chicago, IL
Manager, Medical Management
Chicago, IL
Jakubowski-Baumbach
Chicago, IL
Manager, Medical Management
- Supports supervisors in training, assisting staff with problem-solving, and managing case referrals and work flows
- Evaluates and analyzes data to assure operational effectiveness while meeting or exceeding client objectives
- Assure that Medical Services functions and responsibilities are coordinated with other operating departments of the Plan and Corporate
- Manage budgets and forecast for strategic planning and key initiatives
- Monitors, coaches, and reports staff activity and productivity and assists teams in analysis and monitoring of key utilization targets and trends
- Assists staff in making referrals to community or governmental agencies to coordinate levels of service across all Health Plan functional areas
- Assists in problem solving with providers, claims or service issues
Houston, TX
Medical Management Specialist
Houston, TX
Bergstrom LLC
Houston, TX
Medical Management Specialist
- Conducting medical management and health education programs for customers on government health care programs
- Develops expertise in legal and medical terminology and procedures
- Handles first party medical benefit claims, including fatalities and self-employed wage loss claims. Evaluates and makes decisions regarding coverage. Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases
- Tracks referral according to specified timelines and notifies providers and families of CCS eligibility determinations and referrals, BCC authorizations and/or deferrals
- For California Children Services: May request medical records from providers, may complete and submit CCS referral to local CCS program on same date of identification of potential CCS eligible condition
- This role will include gathering, analyzing and providing data for regulatory reports. This position will represent the company to members
- Coordinates activities with the Home Office on serious or massive injury cases. Notifies company investigative services of cases involving suspected fraud
present
Chicago, IL
Director of Medical Management
Chicago, IL
Eichmann Group
present
Chicago, IL
Director of Medical Management
present
- Generates methods to develop and improve the overall delivery and performance of the department
- Manages all budgets and financial performance of the department
- Assists with contract negations as necessary
- Represents Care Management in interdepartmental committees designed to meet organizational goals
- Develops annual goals and oversight of assigned department/function
- Strives to improve efficiencies of key operational areas
- Implements action plans in an effective and efficient manner aimed at promoting goals/resolving issues
Education
Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
University of North Texas
Bachelor’s Degree in Nursing
Skills
Skills
- Good knowledge of medical terminology
- Ability to speak well on the telephone and maintain a positive telephone personality
- Microsoft Word, Excel, Outlook software and database management systems
- Analytical and problem resolution skills
- Organizational and time management skills and build effective working relationships
- Staggered shifts when necessary
- Occasional on call evening and weekend shifts as necessary
- Verbal and written communication skills
15 Medical Management resume templates
Read our complete resume writing guides
1
VP of Medical Management Resume Examples & Samples
- 8+ years of managed care experience, including Medicaid managed care and Medicare
- 5+ years of managerial experience
- Demonstrated knowledge of health care financial management
2
Medical Management Manager Resume Examples & Samples
- 4+ years experience in Home Care, Care Management or related field; 3+ years of progressive experience in Case or Utilization Management
- Previous Managed Long Term Care experience
- Master’s Degree in Nursing or Health Care Administration
- Case Management certification
3
Associate Director of Medical Management Resume Examples & Samples
- Providing leadership to and being accountable for the performance and direction through multiple layers of management and professional staff in medical management
- Innovating provider - organizational relationships to drive innovation and satisfaction for providers and patients
- Work most often impacts a large business unit
- Developing and executing strategies for medical management in UT to impact affordability, quality and accessibility
- Directing others to resolve business problems that affect multiple functions or disciplines
- Registered Nurse licensed in the State of UT
- 5+ years leading teams
- Experience in Palliative and / or Hospice care
- Business Experience outside of Healthcare
- Ability to convey complex or technical information in a manner that others can understand
- High level of proficiency in MS Office (Excel, Access and PowerPoint)
- Community relationships with Utah provider
- Excellent communication skills, including ability to communicate effectively with various levels of leadership
4
Director of Medical Management Resume Examples & Samples
- Manages all budgets and financial performance of the department
- Establishes and maintains continuity in the planning, development and implementation of policies, operational processes, workflows required to execute organizational strategies and to ensure consistency in process application
- Validates and monitors adherence to implemented policies, procedures, workflows and processes; and compliance requirements
- Anticipates and identifies key source information to analyze problems clearly and determines creative solutions
- Identifies trends, problems and opportunities, conducts root cause analysis
- Implements action plans in an effective and efficient manner aimed at promoting goals/resolving issues
- Strives to improve efficiencies of key operational areas
- Represents Care Management in interdepartmental committees designed to meet organizational goals
- Provides guidance on determination of medical appropriateness through the application of clinical criteria; Performs reviews and participates in the clinical review process
- Attends Medical Director meeting and participates in the inter-rater reliability process
- Generates methods to develop and improve the overall delivery and performance of the department
- Ensures improvement in depth of clinical knowledge and understanding through proactive recruitment, training and development, initiatives and role modeling
- Oversees and leads the clinical oversight of program content, operational review and process measures
- Supports Legal and Compliance Departments with continual oversight and proactive identification of all potential risk management issues and review of contracts and documents for relevance and implementation
- Assists with contract negations as necessary
- MD or DO degree preferred
- Board certification from American Osteopathic Association (AOA) or American Board of Medical Specialties (ABMS) is required
- Director candidates with appropriate experience and RN certification eligible
- 15 years of clinical practice
- Knowledge and understanding of managed care principles and physician reimbursement
- Considerable independent decision making with physicians, members, subordinates, other departmental leaders and external vendors, regulatory and accreditation agencies
5
Medical Management Medical Director Resume Examples & Samples
- Supports medical management of UnitedHealthcare Global members in both domestic and global healthcare environments. Supports providers, facilities and physician advisors in the global healthcare environment. Has a keen understanding of the cultural and operational challenges of global healthcare delivery
- Conducts reviews of global medical cases, including assessment and communication of case direction to the UHCG nurses and logistics specialist related to continued monitoring of care being provided locally or the need for evacuation
- Engages daily and ongoing with frontline UHCG clinical review nurses, reviewing cases electronically or in verbal case discussion, with the goals of achieving evidence-based and data-driven delivery of clinically appropriate and cost-effective care
- Leverages evidence-based medicine, nationally recognized clinical guidelines and global healthcare standards to coach clinical staff and support providers in the provision of
- Unrestricted licensed physician; Board Certified in ABMS primary care specialty - required
- 5 years clinical practice – required
- 2 years experience with utilization management in payor and provider settings - required
- Certification in utilization review or evidence-based guideline utilization - preferred
- Experience in travel medicine and/or aeromedical services - preferred
- Experience in clinical practice in global health arena or with global health emphasis - preferred
- Proficient in utilizing basic Microsoft office tools such as Excel, Word, Power Point, Visio and other tools such as Macros
- Experienced in working and documenting in multiple electronic patient information platforms
- Proficient key-boarding skills required
- Proficient in analysis and interpretation of clinical data sets
- Foreign language skills considered a plus
- Team player and team building skills
- Proven success in change management
- Exemplifies Our United Culture
6
Medical Management Specialist Resume Examples & Samples
- 1+ year of experience with an understanding of Managed Care or Medicare
- Microsoft Office/Suite proficient (Excel, Outlook, Word, etc.)
- Highly organized
- Previous experience in Macess, Facets or Care Compass
- Familiarity with Medical terminology
7
Manager of Clinical & Medical Management Resume Examples & Samples
- Set team direction, resolve problems and provide guidance to members of the team to ensure they meet the established performance metrics and goals
- Take a lead role in developing and participating in new program initiatives and innovations
- Create an environment that supports change and models accountability for staff
- Conduct team meetings, field-based shadowing of team members, caseload auditing, and implement performance improvement plans
- Current, unrestricted RN license in the state of NM ORlicensed social worker or behavioral health clinician (bachelors or higher level degree)
- 2+ years case management / care coordination experience within a medical or behavioral healthcare setting
- Excellent organization, communication, teambuilding, and time management skills
- Ability to proactively partner with care team, including primary care, behavioral health, state partners, and other key stakeholders
- Proficiency in MS Word and MS Excel, to include the ability to create documents and spreadsheets
- Working knowledge of medical and / or behavioral health terminology
- Experience in case management to include assessment, planning, and service coordination
8
Medical Management Supervisor Resume Examples & Samples
- Supervise, train, and assist in the distribution of work assignments, work review, performance appraisal, hiring, etc
- Write, implement, and review of the performance of the AHCCCS Acute Care and Arizona Long Term Care System Health Plans through the Operational and Financial Review process, including the corrective action plans. Technical assistance to Contractors as needed
- Reviews and analyzes the data provided by Contractors/ Health Plans. Tracks compliance with the reporting of the Contractors / Health Plans per contract guidelines/policies or AHCCCS requests
- Develop, update, review and interpret AHCCCS policies, rules and regulations, research changes and additions, identify potential issues, communicate impact of changes to division/agency management
- Reviews, researches and assists in coordination of Transplant Activities for the Tribal Fee for Service members, and provides technical assistance to the Program Contractors/Health Plans regarding transplant policy. Interfaces and reviews compliance of contracted facilities in accordance with the AHCCCS facility contract. Identifies and reports to Manager any deficiencies with facility contract, including outcomes and gaps
- A licensed Registered Nurse, Physician's Assistant or Nurse's Practitioner is required
- Knowledgeable in principles and practices of Utilization Management and Federal Regulations
- Strong analytical and comprehension skills to interpret utilization management data within the context of federal and state statues, policy, rules and regulations
- Ability to multi-task in a fast paced environment, re-organize as needed
- Ability to manage and supervise staff
- Four years clinical experience
- Two to three years supervisory experience
- Experience in writing issue papers, interpreting laws and rules, writing decisions and policies
- Experience in auditing
9
Medical Management Manager Resume Examples & Samples
- Design, implement, monitor, evaluate and continuously improve a Medical Management program for the AHCCCS Acute Care and Arizona Long Term Care System
- Coordinate with other AHCCCS Divisions and with AHCCCS Contractors the compilation and evaluation of Utilization Management data
- Produce written analyses of Utilization Management data gathered from AHCCCS Contractors and from within AHCCCS
- Write, implement, review the Medical Management portion of the Operational and Financial Reviews, including corrective action plans as needed. Technical assistance to Contractors as needed
- Coordinate, monitor and respond to all Utilization Management report requirements for CMS, and other Medicaid oversight bodies
- Conduct reviews of AHCCCS Contractors with regard to Medical Management requirements
- Current, active AZ RN license
- Knowledge of principles and practices of Utilization Management
- Three-five years clinical experience
- Effective management and leadership skills, including organizational and project management
- Strong ability to multi-task in a fast paced environment, reprioritizing as needed
- Four years professional experience related to medical management, which includes program planning or administration
- Master’s degree in the healthcare field
10
Manager, or, Medical Management Resume Examples & Samples
- Requires current unrestricted RN license in Georgia, and 5 or more years acute care clinical and case management experience or any combination of education and experience, which would provide an equivalent background
- Case management/utilization management experience preferred
- Requires knowledge of care management assessment techniques, provider community, and community resources
- Must have good oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills
- Must have previous leadership experience
- May be required to work some corporate paid holidays and/or weekends based on business needs
- Prior or current Medicare Advantage experience
- **May be a level I or II depending upon incumbent's level of relevant skills, experience, and education determined by manager.*****
11
Director, / II Medical Management Resume Examples & Samples
- Requires a BS in a related health care field or nursing
- 5 years of experience in a health care environment (i.e. acute care) including management experience; or any combination of education and experience, which would provide an equivalent
- MS or advanced degree in a clinical nursing specialty, business or healthcare-related field preferred
- Current unrestricted RN license in MO is a plus
12
Medical Management Specialist Resume Examples & Samples
- Requires a high school diploma; 1 year of experience with an understanding of managed care or Medicaid/Medicare; or any combination of education and experience, which would provide an equivalent background
- 2-3 years experience with Utilization Management is highly preferred
- Proficiency in MS Excel preferred
- Extensive knowledge of MS Word and MS Outlook required
- Excellent communication skills over the phone required
- EOE.M/F/Disability/Veteran
- * May be hired as Medical Management Specialist I or II depending upon the level od education, skills, and relevant experience.***
13
Medical Management Specialist Resume Examples & Samples
- Prepares for and participates in the Operational Reviews to include the review of pre-audit documents and policies, on-site audit, formal written documentation of findings, and monitoring the Corrective Action Plans as applicable
- Reviews, researches and approves transplant services for the Tribal fee-for-service members which includes documentation in the transplant database, creating cases in PMMIS and sending letters of approval to the transplant facilities
- Review catastrophic cases to ensure that AHCCCS clinical criteria for reinsurance are met. Creating reinsurance cases and providing written approval letters to each Contractor
- Responsible to review the annual Medical Management/Utilization Management (MM/UM) Plan, Work Plan and evaluation of each Contractor along with written communication outlining any deficiencies that need to be corrected
- Provide technical assistance to the Contractors as needed relating to MM policies, transplant activities or catastrophic reinsurance
- Assists in the review and revision of MM policies and procedures as needed
- Active Arizona licensed RN
- Proficient in principles and practices of medical management; nursing principles and practices
- Excellent oral and written communication skills; ability to communicate with all levels of professionals, corporate and agency officers and members
- Strong ability to multi-task in a fast-paced environment, reprioritizing as needed
- Demonstrated experience using Microsoft Office Products: Word and Excel
- Experience working for an AHCCCS contractor
- Three years of clinical experience
- Utilization management skills
- Behavioral Health experience
14
Medical Management Trainee Resume Examples & Samples
- Study several roles of sales, marketing and supporting activities
- Understand pharmaceutical business and obtain medical expertise
- Study several roles of Quality Assurance, Drug Safety and Clinical Operations
- Involve in the implementation of medical projects/activities
- Conceptual/strategic parts in Medical Affairs Department, as well as several execution roles
15
VP, Medical Management Resume Examples & Samples
- Bachelor's degree in Nursing, related field or equivalent experience
- 10+ years of clinical nursing, quality improvement, and management experience in a managed care setting
- Thorough knowledge of a specialized or technical field such as clinical nursing, managed care, and healthcare administration
- Thorough skills knowledge of quality improvement practices
- Working knowledge of medical information systems, medical claims payment process, medical terminology and coding, case management practices, managed care, and Medicaid programs
- Familiarity of National Committee on Quality Assurance (NCQA) accreditation process and standards
- Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff
16
Medical Management Specialist Resume Examples & Samples
- Managed care or Medicaid/Medicare experience required
- Customer service experience required
- CareCompass experience required
17
Medical Management Specialist Resume Examples & Samples
- Advanced Microsoft Excel skills required
- Knowledge of utilization management preferred
- Experience working with providers preferred
- Strong communication skills required
- Strong organization skills required
- At least 1 year of experience with an understanding of managed care of Medicaid/Medicare required
- At least 1 year of customer service experience required
18
Medical Management Specialist Resume Examples & Samples
- Degree in Healthcare field preferred
- At least 1 year of experience with an understanding of managed care of Medicaid/Medicare preferred
- Microsoft Office experience required
19
VP, Medical Management Resume Examples & Samples
- Direct and coordinate activities of department and aid the chief officer of the health plan and appropriate corporate staff in formulating and administering organizational and departmental policies
- Review analyses of activities, costs, operations and forecast data to determine department progress toward stated goals and objectives
- Serve as a member of management committees on special studies
- Administer and ensure compliance with National Committee on Quality Assurance (NCQA) and/or Joint Commission on Accreditation of Healthcare Organization (JACHO) standards as determined for accreditation of the health plan
- Participate in, attend and plan/coordinate staff, departmental, committee, sub-committee, community, State and other activities, meetings and seminars
- Participate in provider education and contracting, as necessary
- Education/Experience: Bachelor's degree in Nursing, related field or equivalent experience
- License/Certification: Current state nursing license
- License/Certification: Board Certification through American Board Medical Specialties
20
VA MCD VP Medical Management, Mltss Resume Examples & Samples
- 7-10+ years of experience working within the VA MLTSS market
- Must possess extensive relationships with state and city regulators that they can leverage to successfully position Aetnas VA MLTSS plan in the market
- Must possess significant leadership experience developing CM team and protocols for the MLTSS plan
- MLTSS institutional and programmatic knowledge required
- 3 to 5 years of management experience in a health care setting, including management in the areas of Utilization Management/Case Management
- 3 to 5 years experience in patient care setting
21
Manager, Medical Management Resume Examples & Samples
- Implement changes to medical service functions and performance in relation to company mission, philosophy objectives and policies, as directed
- Manage budgets and forecast for strategic planning and key initiatives
- Balance current future needs effectively
- Research and incorporate best practices into operations
- Assure that Medical Services functions and responsibilities are coordinated with other operating departments of the Plan and Corporate
- Responsible for the statistical analysis of utilization data
- Participates in NCQA accreditation of the Plan
- Bachelor’s degree in Nursing or equivalent experience
- 3+ years of nursing experience, including quality improvement experience in a healthcare environment, preferably in managed care
- Preferred Skills: 3-5 years management experience, hospital clinical work experience, proficiency in Excel
22
Medical Management Specialist, / II Resume Examples & Samples
- At least 1 year of LTSS experience preferred
- At least 1 year of managed care or Medicaid experience required
- Strong computer skills required
23
Medical Management Claims Supervisor Resume Examples & Samples
- Bachelor's degree and two years of previous medical management claims adjusting or equivalent experience, required; or �
- Associate's degree and four years of previous medical management claims adjusting or equivalent experience, required; or
- High school diploma or GED and six years of previous medical management claims adjusting or equivalent experience, required
24
VP of Medical Management Resume Examples & Samples
- Directs the development, planning and execution of continual process improvement efforts, policies, procedures, and regulatory compliance functions related to care management activities
- Provides vision and leadership to advance the care management program under WellMed to the next level of service
- Collaborates with physician leadership to execute the implementation of the care management programs as defined by WellMed. Provides information/data to market leadership as requested
- Promotes understanding, communication and coordination of all care management programs components
- Provides oversight for all activities related to delegated and regulatory requirements including: annual health plan delegation audits
- Drives adoption of best practices and trends for UM, CM, DM activities
- Participates in CMS audits of health plans and their delegates
- Monitors/analyzes metrics/data/trends, and ensures areas needing attention are communicated to applicable stakeholders
- Drives UM performance to meet targets for admissions, readmission and total health care costs for Florida
- Assists with the development of the UM Work Plan, Evaluation and the monitoring of the Work Plan activities as they related to clinical performance improvement
- Develops operating budget as necessary and participates on various teams, committees and meetings at WellMed
- Drives and assists in the design of strategic plans and management of Florida, large-scale clinical initiatives, pilots, and projects promoting quality care for seniors
- Directs and oversees innovation initiatives, data analysis activities, and evaluation strategies for clinical programs including, but not limited to, pilot projects, grant-funded research projects
- Registered Nurse (RN) degree with minimum of 10 years’ experience in practice; Active and unrestricted license to practice in any US state with the ability to obtain a Texas license within 90 days of starting employment
- Master’s degree in Healthcare or Business Administration (10 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a Master’s degree)
- 10+ years of management-level experience in managed care, medical management programs required
- Knowledge of federal and state laws and NCQA regulations relating to managed care, and all aspects of Medical Management
- Proven capability working with people at multiple levels organization, prefer multiple locations, multi-function
- Excellent training and collaboration skills; excellent verbal, written communication, presentation, and facilitation skills; presentation SME with market level interface
- Knowledge of fiscal management and human resource management techniques; proven evaluative and analytical skills; ability to analyze data/reports and make recommendations
- Ability and willingness to travel both locally and non-locally as determined by business need
25
Medical Management Intake Rep Resume Examples & Samples
- High School diploma or equivalent, Bachelor’s degree preferred
- Microsoft Word, Excel, Outlook software and database management systems
- Minimum 3 to 5 years of direct experience in managed care or medical management
- Minimum 2 to 3 years of direct experience in a health plan environment
- Must be able to work under pressure, handle stressful situations effectively, and deal politely with subscribers and providers on the telephone, in person, and e-mail/correspondence
- Proficiency Legends
26
Medical Management Intake Resume Examples & Samples
- Manages intake activities via phone, fax, USPS mail and email
- Interacts with the providers or members as appropriate to communicate approval outcomes in compliance with state, federal and accreditation requirements
- Pre-Service Hospital Intake and (Coordination for Review)
- Concurrent DME (Durable Medical Equipment) PA (Prior Authorization) reviews and new case creations
- Discharge Planning UM Coordination
- Monitors, logs and tracks service requests from both Providers and Members in accordance with regulatory compliance
- Accurately applies appropriate criteria based on policies and procedures, member eligibility and plan benefits at the time service is rendered
- Promotes and maintains quality documentation
- Obtains appropriate information for authorization review and case creation
- Responds to out of network inquiries, including providers, hospitals and other outside ancillary providers
- Expedites entry of urgent authorization requests and hospital notifications
- Works collaboratively with other departments to research and resolve issues
- Authorizes specific designated services that do not require medical necessity review, as per company policy
- Organizational and time management skills and build effective working relationships
- Analytical and problem resolution skills
- Good knowledge of medical terminology
- Staggered shifts when necessary
- Experience in intake managed care medical management
27
VP, Medical Management Resume Examples & Samples
- License/Certification: RN with Bachelor's Degree, active unrestricted Nevada state license
- 10 years' experience in operations, Utilization Management and case Management, preferably in a Managed Care Health Plan
- Working knowledge of medical information systems, medical claims payment process, medical terminology and coding, case management practices, managed care, and Medicaid programs. Familiarity of National Committee on Quality Assurance (NCQA) accreditation process and standards
- Previous track record of successful senior level leadership including hiring, mentoring and promoting staff
- Understanding of analytics and metrics with ability to report on findings and outcomes
28
Medical Management Specialist, / II / Senior Resume Examples & Samples
- Requires a high school diploma
- Bachelor's Degree in social work preferred
- Experience in motivational interviewing preferred
- Experience in dealing with substance abuse disorders preferred
29
Medical Management Specialist, / II Resume Examples & Samples
- Requires a High School diploma; minimum of 1 year of experience with an understanding of managed care or Medicaid/Medicare; or any combination of education and experience which would provide an equivalent background
- Bilingual Spanish, Chinese or Russian is a preferred
- Knowledge of MS Word, Excel and Data Entry experience required
- Must be able to sit and communicate by telephone for extended periods of time
- Ability to work in a fast paced environment with ability to prioritize work and meet deadlines required
- Understanding of Managed Long Term Care (MLTC) preferred
30
Medical Management Specialist Resume Examples & Samples
- Handles first party medical benefit claims, including fatalities and self-employed wage loss claims. Evaluates and makes decisions regarding coverage. Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases
- Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion
- Investigates complex coverage questions according to applicable state law
- Evaluates, processes and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports. Determines claims to be paid, compromised or contested
- Establishes immediate contact with Policyholders and Claimants. Contacts Agents as necessary
- Coordinates activities with the Home Office on serious or massive injury cases. Notifies company investigative services of cases involving suspected fraud
- Reviews claim files on a regular basis and takes necessary follow-up and/or closing action
- Assists defense counsel in trial preparation of litigated medical management claims
- Attends industry-related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department
- Assists or acts on the behalf of supervisor when required, including handling of insurance department complaints
- Develops expertise in legal and medical terminology and procedures
- Assists in training branch office personnel in related matters
- Assigns, monitors and controls activities of vendors in a cost-effective manner
- High School Diploma or GED and two years of related experience required, or
31
Senior VP, Medical Management Resume Examples & Samples
- Responsible for Utilization Management, Case Management, Pharmacy Services, Clinical Account Management, and Clinical Vendor Delegation
- Lead a team of over 700 FTEs in multiple geographic locations
- Lead integration efforts including insourcing Case Management and system conversion
- Co-Owner of HBR Initiatives
- Builder: ability to turn a weaker department into a strength for the company
- Turn philosophy into an operating construct
- Direct efficient & effective care: right place, right time, right caregive
32
VP, Medical Management Resume Examples & Samples
- Leads, directs, and oversees quality management and improvement activities, including risk management, performance improvement and patient safety
- Develops strategic plans, policies and procedures to improve quality throughout the organization and its network, and works with leadership to ensure compliance with all regulatory agencies
- Oversees the adherence to company metrics and targets and reports on trends and ratings related to quality systems across the organization
- Ensures high quality patient care to all patients receiving services covered by CareConnect
- Directs and manages resources efficiently and timely for all quality performance initiatives and activities
- Conducts analysis audits and studies to research any quality of care issues
- Ensures clinical staff meet defined goals, targets and regulatory requirements. Develops and applies performance metrics to evaluate services, employee performance, and program outcomes Identifies, develops and maintains relevant quality training programs to ensure employees receive training related to their work and ensures training is properly documented
- Selects, develops, manages and evaluates direct reports; and oversees the selection, development, management and evaluation of indirect reports
- Collaborates with leadership, medical director(s), medical management staff, and other employees of CareConnect to plan, formulate and develop new and improved quality procedures
- Master’s Degree in Nursing or related field, required
- Minimum of ten (10) years clinical care management experience including five (5) years leadership experience in a health plan organization, required
- Strong leadership skills and ability to manage change across different environments. Must possess solid organizational and management skills necessary to meet established targets and deadlines. Ability to initiate, create and maintain relationships at all levels of the organization
33
VP Medical Management Resume Examples & Samples
- Provide exceptional leadership to the medical Management Staff. Ensures all department functions are staffed appropriately and that all department processes are completed by department staff in a timely and accurate manner
- Identifies opportunities for employee and process improvements and ensures training and skill development is provided either through direct involvement or delegation to the management team
- Develops and implements annual reviews of the results of the Quality Improvement and Utilization Management plans
- Develops and facilitates the successful performance of medical management processes, policies and procedures to assume that medically necessary services are delivered efficiently, at optimal cost and in an efficient manner
- In partnership with others, identifies areas of over or under clinical utilization through the use of data and tools provided by the Finance and Decision Support departments
- Develops, monitors and implements department budget
- Minimum of 10 years’ experience in medical management with IPA’s, medical groups or HMO’s
- 5-7 years’ experience with an IPA or medical group. Prior medical management experience of multiple departments of functional areas within a managed care setting
- Familiarities with Federal and State governmental care regulations and accrediting agency requirements
- Bachelor’s degree in Nursing or healthcare related field. Master’s degree in Business Administration or health care related field preferred
- Current California RN license is required
- Experience and knowledge of HIPPA rules and regulations along with a strong background in strategic planning, financial analysis and contract negotiations
34
Manager, Medical Management Resume Examples & Samples
- Assists in the development and implementation of new or revised programs. Monitor progress, develop recommendations for improvement, and monitor action plans to ensure the integrity of the programs are maintained and deadlines are met
- Assists in the development of and revision of care management programs, policies and procedures
- Assists staff in making referrals to community or governmental agencies to coordinate levels of service across all Health Plan functional areas
- Conducts regularly scheduled team meetings to communicate key information, engage staff in daily operations, and provide ongoing staff education related to all relevant areas of Medical Management while nurturing a team approach
- Facilitates detailed case reviews with appropriate Health Plan team members including physicians to identify barriers to care and initiate appropriate team coordination
- Monitors, coaches, and reports staff activity and productivity and assists teams in analysis and monitoring of key utilization targets and trends
- Performs duties and responsibilities in accordance with the philosophy and standards of the UPMC Health Plan, including conveying courtesy, respect, enthusiasm, integrity, innovation and a positive attitude through contacts with staff, health plan members, peers, and external contacts
- Serves as a resource to staff and other Health Plan departments to identify opportunities for improvements, quality of care concerns, barriers and root causes, and participates in the member complaint and grievance process
- Supports supervisors in training, assisting staff with problem-solving, and managing case referrals and work flows
- Masters Degree in health related profession required
- Five years of clinical experience required
- Three years of experience in a managed care environment required
- Prior management, supervisory, or leadership experience required
- Excellent interpersonal and communication skills (verbal and written) required
- Strong organizational and problem-solving skills with the ability to make decisions independently
- Proficiency with Microsoft Office products required
- Ability to develop and maintain an effective team-focused working environment
- Ability to analyze data and identify trends
35
Medical Management Specialist Resume Examples & Samples
- Associates or Technical Degree preferred
- At least 2 years of experience in the medical field required
- Medical terminology knowledge required
- Strong typing skills required
- Excel experience required
- Experience in an office based production environment required
36
Medical Management Specialist Resume Examples & Samples
- High school diploma, GED or equivalent
- Minimum 1 year of customer service experience in a call center setting
- Minimum 1 year of experience with an understanding of managed care or Medicaid/Medicare; or any combination of education and experience, which would provide an equivalent background
37
Medical Management Specialist, / II / Senior Resume Examples & Samples
- Strong computer skills MS Word, Excel, Outlook and medical management systems
- Excellent oral, telephonic and written communication skills
- Must be organized, professional and able to work in a team environment
- Flexible to change priorities and tasks based upon business needs
- Prior Managed Care experience preferred, specifically knowledge of Medicaid
- Care Compass and Facets experience preferred
- Call Center (Customer Service) experience preferred
- Current knowledge/experience with Anthem Inc. systems preferred
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Medical Management Specialist Resume Examples & Samples
- Conducting medical management and health education programs for customers on government health care programs
- This role will include gathering, analyzing and providing data for regulatory reports. This position will represent the company to members
- Current/active IL Nursing License
- 2 years direct clinical care to the consumer in a clinical setting
- 3 years wellness or managed care experience presenting clinical issues with members/physicians
- Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources
- PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications
- Bilingual in English and Spanish. (Preferred)
- Experience in managing complex or catastrophic cases. (Preferred)
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Medical Management Operations Manager Resume Examples & Samples
- Conduct research and functional needs analyses for issues within the Healthcare Management Services areas (including both Corporate and Health Plan levels), Identify gaps and make recommendations for changes to improve policies, procedures, programs and operations
- Develop and execute tracking tools for reporting
- Remain aware of any potential problems and works to mitigate any risks
- Monitor project deliverables and progress through continuous communication with project members
- Provide support to staff during implementations and transition cycles
- 5-7 years of experience in program management, and vendor management required
- 5 years of current experience in healthcare management in a managed care setting and 3 years of leadership, leading, and/or management experience preferred
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Associate Director of Medical Management Resume Examples & Samples
- Takes a key role in setting direction and participating in or developing new programs
- Responsible for working closely with trainers to initiate procedures and audits necessary for national Accreditation for Complex Case Management and in the future UM and DM
- The Associate Director works collaboratively with the members, providers, PCP Network, and other departments to maximize member’s benefits within a cost effective environment
- Identify compliance and quality improvement opportunities and collaborates with Quality area
- Assist in implementing procedures to provide excellent customer service to our clients through but not limited to communication, staffing, phone availability and service execution
- Responsible for reports including identifying areas of concern and suggesting how to track and trend the outcomes along with regulatory oversight
- Participate in onsite meetings and JOCs with Facility Leadership and Providers to discuss current CM trends and how to improve patient outcomes
- Current and unrestricted RN license in the State of Arizona
- 5 or more years of Case Management/UM experience
- 5 or more years of Leadership/Management experience
- 5 or more years of clinical nursing experience
- Ability to obtain CCM within 2 years
- Medicare and Managed Care work experience
- SNF environment experience
- Current Certified Case Manager (CCM)
- Master’s Degree in Nursing or health related field
- Background in NCQA Accreditation for Complex Case Management
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Supervisor, Medical Management Resume Examples & Samples
- Supervise and maintain departmental and organizational standards and measures, plan and implement work flows to prioritize competing and interdependent tasks to meet deadlines and manage time effectively
- Supervise and adhere to professional standards, organizational policies and procedures, Federal, State, and Local requirements
- Supervise individuals who administer quality services to serve patient needs and maintain profitability
- Transcribe, format, input, and edit information or data to create letters, documents, spreadsheets, and graphic presentations
- Supervise the storage and retrieval of files in accordance with established procedures to ensure the timely access of information and records
- Identify problems; examine solution options; implement action plans; provide resources to resolve quality issues
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Medical Management Specialist Resume Examples & Samples
- FACETS experience is preferred
- Customer service background in the healthcare industry preferred
- Must currently reside in one of the following Central Region states: Ohio, Indiana, Kentucky, Missouri, Wisconsin, Georgia, and/or Tennessee
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Medical Management Specialist Resume Examples & Samples
- Multiple positions are available, with 50 - 75% in-state territory travel with Work from Home potential**
- Registered Nurse (RN), Licensed Professional Counselor (LPC), Licensed Clinical Professional Counselor (LCPC), Licensed Master Social Worker (LMSW), Licensed Social Worker (LSW), or Licensed Clinical Social Worker (LCSW) with 2 years direct clinical care to the consumer in a clinical setting
- Current Illinois drivers license, transportation and applicable insurance
- Ability and willingness to travel within assigned territory
- 3 years clinical experience
- Patient education experience
- Condition Management experience
- Experience in managing complex or catastrophic cases
- Certification in Case Management, Training, Project Management or nationally recognized health care certification.IL - Belleville, IL - Chicago, IL - Champaign, IL - Quincy, IL - Springfield, IL - Rockford, IL - Aurora, IL - Mattoon, IL - Downers Grove, IL - Naperville, IL - Danville, IL - Waukegan, IL - Marion, IL - Jacksonville
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Medical Management Specialist Resume Examples & Samples
- Note: This is a ‘Work from Home’ field-based position that will require making visits to members homes.**
- This position is located in Gallup, NM or Grants, NM**
- Certification in Case Management, Training, Project Management or nationally recognized health care certification.NM - Grants, NM - Gallup
