Medical Management Resume Sample
Rex Sporer
929 Fritz Bridge,
San Francisco,
CA
+1 (555) 687 4428
Work Experience
Medical Management Specialist
09/2015
-
PRESENT
Phoenix, AZ
- Experience in a medical setting including knowledge of medical terminology
- Qualification 2: Working knowledge of Microsoft Excel and formulas helpful but not required
- Implement changes to medical service functions and performance in relation to Medicare guidelines, company mission, philosophy objectives and policies
- Manage budgets and forecast for strategic planning and key initiatives and balance current future needs effectively
- Assure compliance of work processes with Medicare Advantage and CMS regulations
- Medicare or Health Plan experience
- Behavioral Health or Acute Care experience
Medical Management Supervisor
01/2011
-
04/2015
Boston, MA
- Manage budgets and forecast for strategic planning and key initiatives. Balance current future needs effectively
- Directs overall functions of the Medical Management Department and promotes values of teamwork, accountability, empowerment to enforce and maintain positive interdepartmental working relationships for the purpose of streamlining operations and enhancing employee satisfaction
- Directs the identification, implementation, and monitoring of a focused medical management program, annual plan, and annual evaluation for Health Alliance at the corporate level
- Oversees all medical management activities for improvement in care and service and alignment with regulatory standards including but not limited to NCQA, CMS, IFMC, Rural Health Boards, IDPH; develops action plans around identified gaps; and prepares documentation for submission to regulatory agencies to meet requirements
- Analyzes data to monitor trending of quality and utilization practice patterns to identify improvement opportunities that reduce medical spend
- Identifies patterns of care and opportunities that improves the utilization of resources
- Monitors work flows and implements improvements
- Identifies training needs and develops training materials
- Drives improvements in quality whiles slowing the growth in health care spending
Supervisor, Medical Management
12/2006
-
09/2010
Houston, TX
- Demonstrates program outcomes and communicates results with appropriate stakeholders on a regular basis
- Responsible for the transition of care process across multiple levels
- Manages outsourced services related to medical management
- Evaluate and report quality and medical management activities routinely at the Health Alliance Quality Improvement Committee, Medical Director Committee, Joint Venture Partners, and Quality Committee (subcommittee of the Health Alliance Board)
- Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment protocols
- Regularly engages in peer-to-peer dialogue with practicing physicians and physician advisors about the care of individual inpatients to develop collaborative intervention plans based upon EBM
- Works collaboratively with international and domestic healthcare providers and internal clinical and operational teams to assure high quality cost-effective care management, proactive discharge planning, optimize reduce readmission risk and optimize patient health
- Initiates and maintains verbal and/or electronic communication with all appropriate stakeholders (patients, providers and clients) related to the status and action plans for the case
Education
Western Carolina University - Asheville
2002 - 2006
Bachelor's Degree in Nursing
Professional Skills
- Effective management and leadership skills, including organizational and project management skills
- Demonstrated project planning and scheduling skills for large system projects
- Strong typing skills with accuracy
- Strong interpersonal skills at all levels from team members to senior level leadership
- Excellent customer service and communications skills- Required
- Typing skills of at least 40 works p/m
- Strong understanding of, and experience with Microsoft Excel, Access and Outlook
How to write Medical Management Resume
Medical Management role is responsible for leadership, basic, training, intermediate, computer, excel, typing, education, finance, integration.
To write great resume for medical management job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Medical Management Resume
The section contact information is important in your medical 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 Medical Management Resume
The section work experience is an essential part of your medical 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 medical 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 medical management position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Medical Management resume experience can include:
- Adheres to clinical documentation standards to ensure efficient case review, communication with team members and to facilitate timely and efficient determinations and claims adjudication
- Participates in the management of complex medical cases and collation of clinical information to assess and expedite assessment of care needs. This includes obtaining and reviewing verbal and written medical reports/records
- Good written and oral communication skills are very important
- Demonstrated experience in the principles of medical management/utilization management
- Analytical and comprehension skills to interpret utilization management data within the context of federal and state statutes, rules and regulations
- Intermediate Word, SQL/Query and Excel skills
Education on a Medical Management Resume
Make sure to make education a priority on your medical management resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your medical 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 Medical Management Resume
When listing skills on your medical 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 medical management skills:
- Treatment and Discharge Planning experience; effectively manage staff that provide case management services
- Excellent computer skills needed
- Three to five years Supervisory experience; effectively manage individuals who provide quality Case and Disease Management services to members required
- Experience in cost stewardship using Lean principles or other means which increase effectiveness and cut waste
- Prior experience providing non-clinical support for a team of clinicians in case management and/or utilization management
- Home Care and/or Care Management experience; 3+ years of progressive experience in Case or Utilization Management
List of Typical Experience For a Medical Management Resume
1
Experience For Medical Management Specialist Resume
- Experience with word processing/spreadsheets including Excel
- Computer application experience
- Reinsurance medical management experience
- Three to five years Utilization Management/Case Management experience
- Coordinate and manage Health Services Management functions provided by non-market services e.g., certain UM, claim processing, contracted MH/CD services, etc
- Serve as liaison with regulatory and accrediting agencies and other Health business units
- Develop project plans and tracking multiple projects simultaneously
2
Experience For Manager, Medical Management Resume
- Support and coordinate system related needs; provide technical support and performing tests on system modifications; compile test plans and test results
- Coordinate and deliver research of data, identify trends and best practices for reporting to state
- Provide outreach and training to providers
- Supervise, train and assist in the distribution of work assignments, work review, performance appraisal, hiring, etc
- Principles and practices of medical management; nursing principles and practices
- Provide initial customer contact for incoming calls. Perform outbound calls to providers as needed to obtain additional information needed to certify cases
- Ensure timely responses from Aulani to partners’ regarding requests for information
3
Experience For Medical Management Supervisor Resume
- Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) with 2 years direct clinical care to the consumer in a clinical setting
- Pro-actively engages providers and physician advisors globally to review, discuss, and develop solutions for complex member situations
- Engages in provider and facility quality assurance review, policy and procedure development as determined by business need
- Conducts high cost claims reviews for individual cases and engages in high cost claims reviews rounds
- Serves as a clinical educator and facilitates achievement of appropriate patient care goals through coaching of nurses and conducting peer-to-peer communication with practicing physicians globally
- As needed, participates in other utilization management activities driven by business need
- Collaborates with physician leadership to execute the implementation of the care management programs as defined by WellMed
4
Experience For Medical Management Manager Resume
- Provides information / data to market leadership as requested
- Develop and manage a MLTSS Health Services organization (e.g., Network, Quality, Healthcare, Clinical Coverage policy; market based or regional health services) focused on improving clinical outcomes, member satisfaction with providers and provider satisfaction
- Focus on business and program development in a new market; develop strategic business and marketing plans to drive MLTSS membership
- Lead new market implementation and day-to-day care management operations
- Supervise and mentor a team of professionals; ensures that team members have appropriate training and are empowered to pursue professional development objectives
- Procures ancillary services and identifies other home health services to attract and drive MLTSS membership
- Coordinate market medical management business plans & provide strategic and operational direction for the delivery of performance based medical management
5
Experience For Director of Medical Management Resume
- Analyze and report business performance data to customers and colleagues
- Provide appropriate, timely management of complex clinical issues
- Project lead for implementing medical management systems and related technologies and interfaces; coordinate upgrades and new software to support acquisitions and new products
- Coordinate data analysis needs for implementation and report specifications (both operational and regulatory)
- Conduct root cause and current state analysis and make recommendations for process redesign and improvement as supported by new technologies
- Customization of products to meet Amerigroup business rules
6
Experience For Medical Management Intake Resume
- Act as functional lead for all Amerigroup system technology development as related to Healthcare Management Services (including both Corporate and Health Plan levels)
- The Associate Director works collaboratively with the members, providers, PCP Network, and other departments to maximize member’s benefits within a cost effective environment
- Three to five years Supervisory experience; effectively manage individuals who perform Utilization Review
- Experience working in a heavily regulated environment; monitoring compliance of departmental policies and procedures to meet organizational initiatives and regulatory requirements
- Oversee utilization management of all program areas
7
Experience For VP, Medical Management Resume
- Analyze and resolve complex policy coverage issues
- Liaison to the client for all healthcare program areas
- Provide policy and process improvement recommendations
- Analyze and resolve difficult medical coverage policy issues
- 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
- Current, active AZ registered nurse license, Physician’s Assistant or Nurse’s Practioner required
- Computer system knowledge in Outlook, Work and Excel
- Active/Current Arizona RN license
- Able to work in a call center environment
8
Experience For Medical Management Specialist, / II / Senior Resume
- Serve as point of contact for Aulani worker’s compensation claims
- Review Company Nurse incident reports and determine appropriate follow-up steps with leaders
- Facilitate Aulani’s Return-to-Work Program and work with leaders and partners on appropriate and timely return to work of injured Cast Members
- Facilitate the permanent accommodation process if required
- Act as an Agency Subject Matter Expert for clinical concerns; provide technical assistance, review Director’s Decisions regarding member care, intervene for “care needed today” cases; monitor and evaluate all aspects of medical management, including care coordination, high needs/high cost, behavioral health, and ALTCS case management
9
Experience For VP Medical Management Resume
- Support policy efforts related to medical management, including drafting newly identified areas as well as revising current policy. Ensure clarity and evaluate MCOs on implementation and compliance
- Participate in Agency initiatives as appropriate, including but not limited to Requests for Proposals, Mental Health Parity, Targeted Investment, Justice Reach-In, and others as identified
- Interface with transplant facilities, address claims concerns related to transport, support DHCM finance with questions regarding reinsurance and other payments, and support overall efforts related to transplant efforts for all AHCCCS population
- Manage a team of professional staff to support ongoing learning and development, provide guidance and resources as needed, and support problem solving; conduct regular 1:1s; recruit for new staff as needed
- Experience handling medical management programs and health educations programs in an independent manner
- Analytical experience including medical data analysis
- Leading and directing multiple medical management functions and employees, using influence to drive staff to achieve results and organizational collaboration
10
Experience For Medical Management Medical Director Resume
- Supervise the selection, training, development, appraisal, and work assignments, staffing and productivity of Associates within Medical Management
- Manage and supervise the selection, training, development, appraisal, and work assignments, staffing and productivity of Associates within Medical Management
- Ensures appropriate application of existing review criteria (MCG) in the Utilization Review Process
- Supervises daily activities of Medical Management clinical staff, individually and as a team to ensure the following objectives are met
- Perform utilization review of inpatient admissions, and outpatient surgeries, as necessary to ensure turnaround times and processing times are met
- Responsible for ensuring staff compliance with URAC/NCQA requirements
- In the absence of the Director of Medical Management conducts morning rounds
- Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review)
List of Typical Skills For a Medical Management Resume
1
Skills For Medical Management Specialist Resume
- Experience with an understanding of managed care or Medicaid/Medicare; or any combination of education and experience which would provide an equivalent background
- Experience with an understanding of managed care, Medicaid/Medicare, quality improvement, medical records; or any combination of education and experience, which would provide an equivalent background
- Treatment and Discharge Planning experience; effectively manage staff that provide Utilization Review services
- Related work experience, with at least 5 years of Managerial experience
- Intermediate proficiency computer skills, especially with MS Excel
- Customer service experience required; or any combination of education and experience, which would provide an equivalent background
- Competency in MS Office suites (Word, Outlook and Excel) as well as basic computer skills
- Prior knowledge and experience with Medicare Advantage
2
Skills For Manager, Medical Management Resume
- Training and experience with Facets
- Four years professional experience related to medical/utilization management, which included program planning or administration
- Ensure the effective planning and execution of case management, utilization review, and related outreach programs
- Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective
- Experience working with clinical databases (Facets and Macess)
- Combined nursing, quality improvement and managed care experience
3
Skills For Medical Management Supervisor Resume
- Knowledge and experience in one or more of the following medical management and clinical guidelines systems: Facets, Macess, Interqual, Milliman
- One-two years’ experience working for an AHCCCS contractor
- Experience working with health insurance in healthcare settings
- Experience with an understanding of managed care or Medicaid
- Experience with word processing/spreadsheets
- Experience in home care, care management or related field, including
- Multi-task in a fast-paced environment, reprioritizing as needed
4
Skills For Medical Management Manager Resume
- Multi-task in a fast paced environment, reprioritizing as needed
- Demonstrated knowledge of principles and practices of medical management; nursing principles and practices
- Experience with an understanding of managed care or Medicaid/Medicare
- Demonstrated knowledge of Healthcare Financial Management
- Delineate measurable goals to monitor the effectiveness and progress of the medical management program
- Able to work in a fast paced environment with ability to prioritze work and meet deadlines
- One year of experience with an understanding of managed care or Medicaid/Medicare
5
Skills For Director of Medical Management Resume
- Customer Service experience (in person or over the phone)
- Experience with Medicaid, Medicare, Utilization Management, Managed care
- Experience with Facets, Care Compass, Macess
- Experience in call center work environment
- One year of administrative and customer service experience with knowledge of managed care or Medicaid/Medicare concepts
- At least one year call center experience required
6
Skills For Medical Management Intake Resume
- Experience working in managed care
- Experience working with Medicare and/or Medicaid
- Experience with Medicaid/Government Programs
- Experience Microsoft Office (Excel, Word, and Outlook)
- Experience Microsoft Office (Excel, Access, Word, and Outlook)
- Current, valid, unrestricted license in the state of operations (or reciprocity)
7
Skills For VP, Medical Management Resume
- Previous leadership experience (team lead or manager)
- Experience and knowledge of New Jersey FIDE requirements for D-SNP
- One-two year’s behavioral health experience
- Knowledge of MS Word, Excel and Outlook experience required
- Experience with development of innovative and focused partnerships and programs which challenge the norm to support an ever changing healthcare environment
- Demonstrated leadership that cultivates others to exceed and develop
- Claims experience at a health plan
8
Skills For Medical Management Specialist, / II / Senior Resume
- Experience with and knowledge of worker’s compensation, medical accommodations, return to work management
- Experience with Medicaid in any capacity
- Able to work in a fast paced environment with ability to prioritize work and meet deadlines
- Experience with knowledge of managed care or Medicaid/Medicare concepts
- Experience with Microsoft Word, Excel, Outlook and PowerPoint required
- Registered Nurse (RN) with 3 years clinical experience in NICU and/or Labor and Delivery
- Administrative and customer service experience
- Experience in the medical field required
9
Skills For VP Medical Management Resume
- Microsoft Office (Excel, Outlook) experience required
- Administrative and customer service experience with knowledge of managed care or Medicaid/Medicare concepts
- MCO case management experience
- Experience with Clinical Decision Support tools (i.e.: MCG, M&R, etc...)
- Basic knowledge and experience with Microsoft Excel required
- Identify innovative portal solutions for improved provider experience
- Contact for providers for prior authorization issues
- Working knowledge of HIPAA regulations and requirements
- Nursing/ is desired
10
Skills For Medical Management Medical Director Resume
- Expert ability in implementing change within an organization, ensuring understanding, participation, and ownership
- Participates in the budgetary process including preparation of a departmental budget and monitoring for adherence to ensure growth and profitability
- Monitor and evaluate staff performance, providing continuous training as necessary
- Or more working knowledge and training in GBD Facets
- Participates in routine team meetings, training and ongoing educational activities as well as policy and procedure development
- Is responsible for ongoing compliance with existing Contractual and regulatory standards within the Medical Management Department
- In-depth understanding of the dynamics of Health Services Delivery
- Participate in the planning, development, and implementation of major policy and business initiatives
List of Typical Responsibilities For a Medical Management Resume
1
Responsibilities For Medical Management Specialist Resume
- Responsible for all supervisor aspects of the Medical Management department (Case Management/Utilization Management), including
- Participates in work groups and committees oriented toward improving health plan operations
- Provide direction and oversight of the Contractor’s Notice of Action process. Conduct regular audits and provide technical assistance as needed
- Performs data analysis for clients, senior underwriting management, sales/marketing and actuarial departments by summarizing data resulting in meaningful reports, comparison grids, scorecards, audit planning and result reports. Assume full accountability for audit results and action plans
- Leads and manages ongoing team/department special projects and organizes or participates in committee meetings as subject matter expert, leader, or team member; client audits and client presentations as required
2
Responsibilities For Manager, Medical Management Resume
- Contributes actively to and supports the leadership team in developing plans, coordinating activities and in assuring all departments are aware of key activities in the department. Ensures work area goals contribute to accomplishing departmental and RGA Re objectives
- Collaborates with the Director of Medical Management and the Medical Director to facilitate provision of services throughout the health care continuum and participates in Health Plan related initiatives
- Identify and refer quality issues to the Director of Medical Management or Medical Director
- Provides supervision and clinical leadership to Medical Management staff
- Supervises utilization management activity and referrals to the Medical Director
3
Responsibilities For Medical Management Supervisor Resume
- Supervises case management and disease management referral activity from utilization management
- Conducts reliability audits of the internal review process to monitor compliance with performance standards and submits to the Director of Medical Management to develop action plans to address areas needing improvement
- Collaborate with Claims, Quality Management and Provider Relations Departments as requested
- Responsible for development and maintenance of policies and procedures for department
- Responsible for HIPAA and Integrity compliance within department
- Works closely with department Director to identify and plan for opportunities for improvement within areas of responsibility
- Collaborate with and maintain open communication with all departments within CHRISTUS Health and US Family Health Plan to ensure effective and efficient workflow
- Responsible for all management aspects of the Medical Management department (Case Management/Utilization Management), including
- Responsible for daily operations of the Medical Management Department
4
Responsibilities For Medical Management Manager Resume
- Responsible for all reporting and report preparation functions within the Medical Management Department, including quarterly reports to the CQI Committee and Department of Defense
- Provides strategic direction and clinic al lead ership in the development of all MCB departments including interpretation and implementation of appropriate medical/benefit policies and the Clinical Trials Unit for the Service Benefit Plan, Operations Center, Office of Personnel Management and National Programs
- Leads strategic cross-functional projects/teams working with PMO to develop project scope and outcome measures, assuring that operational components are addressed to meet Plan business needs and execution while ensuring projects
- 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
- Ensure compliance (Medicare) of medical and clinical operations programs and services
- Evaluate and analyze data to determine program needs to improve quality and affordability
- One 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
- Background in Medical Terminology
- Intermediate Proficiency with Microsoft Suite Programs
5
Responsibilities For Director of Medical Management Resume
- Bilingual in either English/Korean OR English/Chinese (Cantonese/Mandarin) OR English/Vietnamese OR English/Spanish (Applicants required to take the Berlitz language assessment.)
- Intermediate proficiency with Microsoft Outlook, Word and Excel required
- Extremely focused and detail oriented
- Intermediate computer proficiency with Microsoft Excel, Microsoft Word and Microsoft Outlook
- Regional relocation is available
- Experience with an understanding of managed care or Medicaid/Medicare; or any combination of education and experience, which would provide an equivalent background
- Experience with an understanding of managed care or Medicaid/Medicare
- Experience with an IPA or medical group. Prior medical management experience of multiple departments of functional areas within a managed care setting
6
Responsibilities For Medical Management Intake Resume
- This is a "work from home" position. We are looking for candidates in the Eastern and Central Regions who are in the Eastern Standard Time Zone
- Certification in Case Management, Training, Project Management or nationally recognized health care certification.NM - Albuquerque
- Solution driven using detailed quantitative analysis and process expertise
- Additional job-related and company approved certifications such as Certified Nursing Assistant, Certified Medical Assistant or Certified Med Aid
- Intermediate Computer Proficiency with MS Word, Excel and Outlook
- Competent in MS Office suite to include Word, Outlook and Excel, as well as have a comfort level with computers in general
- Intermediate proficiency on the computer, especially with MS Excel
- Current NM drivers license, transportation and applicable insurance
- Proficiency in Excel, Word, and Outlook required
7
Responsibilities For VP, Medical Management Resume
- Hours required are 8:30-5:00PM EST at the Richmond, VA office location
- Current unrestricted RN license in MO is required
- Experience in a health care/delivery environment including management experience; or any combination of education and experience, which would provide an equivalent
- Current active unrestricted RN license to practice as a health professional within the scope of practice in the State of Nevada, and 5 years acute care clinical experience, 2 years of prior management experience, or any combination of education and experience, which would provide an equivalent background
- Certification in Case Management, Training, Project Management or nationally recognized health care certification
- Current IL drivers license, transportation and applicable insurance
- Current Illinois driver's license, transportation and applicable insurance
- Hours required are 8:30-5:00PM ET at the Hanover, MD office location
- Current NM driver's license, transportation and applicable insurance
8
Responsibilities For Medical Management Specialist, / II / Senior Resume
- Proficiency in Microsoft Applications, preferably excel
- Experience with managed care services including population health initiatives, Affordable Care Act, Coordinated Care Organizations, Accountable Care Organizations, Medicare and Medicaid regulations
- Type 40 WPM without error
- Microsoft Outlook, Word, and Excel knowledge required
- Health care/medical terminology knowledge required
- Work independently and multi-task between programs
- Proficiency in MS Word, Excel, Outlook, and PowerPoint
- This is a telephonic position that could potentially be remote/work from home after 3 weeks of orientation at the HQ
9
Responsibilities For VP Medical Management Resume
- Knowledge of managed care or Medicaid/Medicare concepts
- Hours required are 8:30-5:00PM EST at the Hanover, MD office location
- Current IL driver's license, transportation and applicable insurance
- Work from home is required
- Administrative and customer service experience with knowledge of managed care or Medicaid/Medicare concepts; or any combination of education and experience, which would provide an equivalent background
- Registered Nurse (RN), Licensed Professional Counselor (LPC), Licensed Clinical Professional Counselor (LCPC), Licensed Master Social Worker (LMSW), Licensed Social Worker (LSW), Licensed Clinical Social Worker (LCSW) OR Licensed Mental Health Counselor (LMHC) with 2 years direct clinical care to the consumer in a clinical setting
- Leadership skills in project management and/or training
10
Responsibilities For Medical Management Medical Director Resume
- Experience with NM Medicaid Programs
- Experience with Authorization of Claims Payment Systems
- Progressive experience in case or utilization Management, required
- Maintains and updates tracking databases
- Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information
- Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability
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