Career Summary: Over 20 years of experience in Acute Care and Health Service programs including Utilization Review, Provider Dispute Resolution, Quality Management, Inpatient and Ambulatory Case Management, and Grievance and Appeals in a managed care environment for both Health Plan and IPA/MSO settings using evidence based nationally recognized criteria such as ACOG, NCCN, MCG, InterQual and Health Plan Medical guidelines and policies. Provided fiscally-sound medical benefit administration, strategic planning and professional leadership of effective healthcare programs compliant with NCQA, CMS, DHCS, and DMHC regulatory requirements for Commercial, Medicare, and Medicaid lines of business. Blue Shield of California Rancho Cordova, CA. Dec 2014 - Mar 2017 Sr. Manager Utilization Management Responsible to direct concurrent review functions for the state of California commercial and Medicare books of business. Execute cost-containment initiatives and strategies manage performance metrics, and ROI targets for medical care management programs. Ensure teams meet/exceed financial targets, personal performance and quality improvement goals. Develop and implement policies/procedures and training programs to support department and enterprise strategic initiatives which effectively represent the company. Accomplishments: * Used statistical analysis to move performance of Utilization Management team from loosely to well managed industry benchmark in nine-month period exceeding overall performance targets. * Revised New Hire Training curriculum to improve initial performance and reduce training time by 50% * Exceeded department average length of stay targets and cost of health care goals by 6% * Revised department workflows and desktop procedures for effortless migration to new operating system Implemented Clinical Onsite Review reducing average length of stay by 1.9% netting cost of health care savings of 3million in programs first year. Molina Health Care Plan Long Beach Feb 2014 - Oct 2014 Director of Utilization Management Responsible for the optimization of all utilization management activities as related to prior authorization, concurrent review, Community Based Adult Services, California Children Services and Behavioral Health care delivery programs within the Medicaid, Accountable Care Act Initiative (CCI) and Medicare lines of business for Molina Health Plan. Responsible to coach/ manage teams, contribute to the clinical quality, financial and patient satisfaction outcomes and compliance with all regulatory requirements. Accomplishments: * Through data mining activities improved identification and capture of CCS eligible cases increasing cost savings by 32% and closing DMHC corrective action. Improved CCS appeal success rate by 15%.

Highlights:

• Compliance
• Management
• Quality Management
• Assessments
• Medical
• Medicare
• registered nurse
• healthcare
• Managed Care
• Utilization Management