Case Management Specialist Resume Sample

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Rubye Towne
970 Treutel Canyon,  Boston, MA
+1 (555) 837 0699

Work Experience

Case Management Specialist
02/2016 - PRESENT
Phoenix, AZ
  • Responds to all fraud-related and investigative requests, including inquiries from law enforcement, external agencies, other financial institutions and internal partners as appropriate, and provides information as per existing policies and procedures
  • Effectively manages the daily intake of investigative requests and fraud incidents reported to GSI, ensuring information received is properly assessed, processed and/or escalated
  • Liaises with various internal and external partners to review investigative requests, determine if requests can be investigated and ensure all applicable information is received for both internal and external investigations
  • Obtains resources, including evidence to support investigations
  • Conducts risk rating analysis with each investigative request to determine case prioritization, case assignment and escalation
  • Ensures all case-related information is received and properly input into GSI’s case management system (ICMS)
  • Initiates the document-gathering process
  • Shares key information as applicable with other GSI units
  • Gather appropriate requirements to implement and configure software to meet the stated needs
Senior Case Management Specialist
05/2011 - 11/2015
Houston, TX
  • A combination of process management with practical implementation techniques
  • Strong working knowledge of relational databases, preferably Microsoft SQL
  • Works with and responds to Case Management Specialists and Management requests throughout the life cycle of each case; provides the producer with information regarding underwriting or policy issue as required
  • Assists the Underwriting Operations functions by proactively identifying, responding and resolving all Underwriting requirements
  • Works with clients, agents and vendors to ensure requirements are received in a timely fashion for review by appropriate parties
  • Schedules necessary medical requirements and orders required medical and non-medical information such as inspection reports and MVRs or other carrier requested requirements
  • Follows up with producers / vendors to obtain requirements and updates case record. Processes policy issue and required forms for delivery
Conflict Free Case Management Specialist
12/2006 - 03/2011
Boston, MA
  • Ensures life applications are closed after 60 days in underwriting and are processed according to UW Ops guidelines
  • Provides status and guidance to agents and their staff in regard to process
  • Searches and matches requirements to case files and refers complex situations to Case Management Specialists as appropriate
  • Reviews all assigned applications for missing information and/or requirements and requests all administrative requirements as early in the process as possible
  • Collaborate with Case Management Specialists and Management to resolve outstanding underwriting operations issues and concerns
  • Supports Underwriters, Case Management Specialists and Agents to work in a streamlined underwriting operations process and improve overall time service
  • Manage and coordinate all aspects of Case Management with the employee, the Contact Center, other internal partners, and with third party administrators to mitigate legal risk and provide advice and counsel to employees, people managers and human resources contacts as appropriate. (75%)


Indiana Wesleyan University - Cleveland Education Center
2001 - 2005
Bachelor's Degree in Social Work

Professional Skills

  • Conflict management skillsPrevious experience of working in a unionised environment would be advantageous
  • Undertake proactive training and coaching for people managers in case management skills and processes - building confidence and capability
  • Effective communication, telephonic and organizational skills
  • Well-developed customer and relationship management skills
  • Coach business leaders in effectively managing cases and people issues
  • Providing end-to-end processing for the Direct to Consumer line of business
  • This includes servicing the business and processing everything from address changes, initial payment, bene changes, reinstatements, loans and surrenders

How to write Case Management Specialist Resume

Case Management Specialist role is responsible for organizational, finance, credit, training, security, compensation, design, modeling, insurance, travel.
To write great resume for case management specialist job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Case Management Specialist Resume

The section contact information is important in your case management specialist 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
  • Email
  • Telephone number

Work Experience in Your Case Management Specialist Resume

The section work experience is an essential part of your case management specialist 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 case management specialist responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular case management specialist position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Case Management Specialist resume experience can include:

  • Using critical thinking skills and knowledge of policy and legal requirements to review and assess medical documentation to determine if an employee’s request is qualifying within the scope of the leave type
  • Developed communication, mediation, and problem solving skills
  • Demonstrates understanding of Sanofi Genzyme’s business model, and their role in commercializing the business
  • Skill in presenting controversial study findings and recommendations to higher level officials
  • Coordinate with the HR Service Center to provide direction and validate an employee’s payroll and benefits while they are on leave (15%)
  • Facilitate Prior Authorizations, Formulary Exceptions, and/or other step edit requirements for all of Sanofi’s renal products

Education on a Case Management Specialist Resume

Make sure to make education a priority on your case management specialist resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your case management specialist 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 Case Management Specialist Resume

When listing skills on your case management specialist 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 case management specialist skills:

  • Previous customer service experience
  • Support and guide line managers in handling of all employee cases, including disciplinary, grievance, performance and absence management processes
  • Focus on quality control, processing goals, training, team metrics and process improvements
  • Generates Risk-Stratification and Predictive Modeling reports
  • Proficient in key boarding
  • Capable of applying knowledge to handle a majority of complex problems independently and make suggestions to update Quest and SOP’s as needed

List of Typical Experience For a Case Management Specialist Resume


Experience For Senior Case Management Specialist Resume

  • Manages the Care Coordination process while balancing the needs of individual patients with the business realities and necessities of Sanofi Genzyme and US Rare Disease
  • Assists in obtaining insurance approval for enzyme replacement therapy, and proactively plans for maintenance of coverage by working with the patients and their family, healthcare providers, insurance companies, specialty pharmacies, and Sanofi Genzyme Colleagues
  • Attends patient meetings, site visits, conferences and trade shows to educate individuals regarding case management services. Represent Sanofi Genzyme in all venues in a professional manner
  • Experience with data entry/computer literate skills
  • Four to six years recent experience in the case management process
  • Is proficient in the use of Salesforce and in producing data specific reports upon request
  • In-depth understanding of health insurance benefits, relevant state and federal laws and insurance regulations

Experience For Msw-case Management Specialist Resume

  • Identify and handle sensitive issues with opposing opinions, work independently and handle projects or multiple tasks
  • Travel required, up to 25%, possibly weekends
  • Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.Ensures all reference specimens are processed and packed up correctly in a timely manner, meeting pick-up deadlines
  • Collaborate with the physician and health care team on level of care concerns and documentation of variances.Operates and maintains centrifuges daily and logs maintenance performed onto the appropriate log. Troubleshoots as necessary and reports problems/ issues to supervisor immediately
  • Identify appropriate case management referral cases based on information collected from physicians, members of the health care team, families, review of the medical record and use of high risk screening criteria
  • Identify barriers to high quality health care, such as the need for interpreter services and follows through with resolutions

Experience For Conflict Free Case Management Specialist Resume

  • Understand concepts of utilization management and able to determine level of care status and whether the documentation by physicians and health care team supports the level of care
  • Assists with the development of departmental policies and procedures in support of clinical resource management
  • Establish relationships with key personnel both within and outside St. Mary's Hospital to promote effective communication and fully support coordination of care linkages and resource management for the patient and family
  • Collaborate with the physician and health care team on level of care concerns and documentation of variances
  • Organize and prioritize workload to ensure case is processed, issued, and placed in a timely manner while maintaining frequent communication to manage customer expectations appropriately

Experience For Case Management Specialist Msw-fsed Resume

  • Facilitate the 1035 exchange process from initial review to requesting funds and following up with replacing companies for any additional requirements necessary for the insurance and placing inforce of the policy
  • Work closely with systems development team, detailing business requirements pertaining to the new business processes
  • Actively participate in team huddles to ensure we are meeting and exceeding our customer centric metrics
  • Adhere to new business procedures and remain current with changes as they occur
  • Establish relationships with key personnel both within and outside St. Mary's Hospital to promote effective communication and fully support coordination of care linkages and resource management for the patient and familyEnsures all specimen manifests from outreach facilities are received and with manifests maintained in the appropriate log book. Troubleshoots as necessary

List of Typical Skills For a Case Management Specialist Resume


Skills For Senior Case Management Specialist Resume

  • Individual typically has at least 2 yrs of related experience
  • Proficiency in all Microsoft Office applications, including Word, Outlook and Excel
  • Knowledge of current PC technology software including Microsoft Office Suite applications (ORACLE, Word, Excel, PowerPoint and Outlook)
  • Recognize significant financial and environmental program issues needing coordination with specialized staff elements
  • Knowledge of 1035 Exchange processing, SEC 38a-1, tax and state regulations
  • The role supports the key users/super users across the Region to develop all necessary knowledge and understanding of
  • Functional and technical knowledge of legal case management systems
  • Work with Case Management Specialists to support clients, agents, and producers to comprehensively process and proactively manage and monitor the Life application from the initial receipt of application through the final receipt of forms upon delivery

Skills For Msw-case Management Specialist Resume

  • A good command of communication and organizational skills is required to process applications in a timely and responsive manner
  • Obtains Admission, Discharges and Transfers from Health System Acute facilities
  • Researches member eligibility and assigned Population Health Value-Based Program through chosen analytical tool
  • Abstracts meaningful data from the AEHR/clinic medical record of identified high-risk consumers
  • Protects the confidentiality of member information and adheres to company policies

Skills For Conflict Free Case Management Specialist Resume

  • Familiar with basic medical terminology and concepts of care management
  • Actively participates in quality activities by communicating and coordinating with the care management team in the development of tools for optimal consumer outcomes and report findings
  • Ensure that cases are managed promptly in a manner consistent with applicable service protocols, agreements and Company values, agreements, policies and procedures
  • Work with the Compliance & Resolution Team to design and deliver relevant solutions to combat issues and trends within the businesses
  • Ensure all cases are appropriately risk assessed and appropriate support and advice put in place
  • Knowledge of employment law and best practice in case management
  • CIPD or equivalent (desirable)
  • Take calls over the 800 line and process requests as received

Skills For Case Management Specialist Msw-fsed Resume

  • Builds and strengthens relationships with clients, understanding their needs to offer appropriate options for policy retention, supporting their desire to protect the ones they love
  • Decision making authority to implement new processes/procedures
  • Identify, recommend, and implement conservation approaches to enhance asset retention and improve persistency
  • Respond to telephone or electronic escalated or complex inquiries/service requests
  • Workers’ Compensation Claims Management
  • Works with the SUOHC clinicians, EH&S professionals, and Risk Management to strategize the best plan for early return to work and patient recovery for individual workers
  • Works with the worker, clinicians, supervisor/manager, claims adjuster, and human resources personnel to implement the case plan, identify and resolve issues, manage the patient’s transition through the related processes, and facilitate communication between all parties regarding the patient’s care
  • Works with OHC management team to ensure charges are kept reasonable and necessary for all cases managed
  • Quality Improvement and Loss Prevention

Skills For Case Management Specialist Resume

  • Identifies opportunities for improvement in such areas as clinical processes and outcomes, utilization of resources, and data collection
  • One (1) year of professional experience in different aspects of administration and business practices; including design and implementation of policy and procedures, vendor service contracts and improving and updating management practices
  • Knowledge of the Oil Pollution Act of 1990 and the body of policies, regulations and precedents affecting its implementation
  • Knowledge of pollution removal techniques and practices, as well as the mechanisms and resources commonly used by other federal agencies in supporting the large/complex removal activities
  • Three years of clinical experience in a related area
  • One year experience in case management or similar role

Skills For Senior Case Management Specialist Resume

  • Knowledge of Milliman and Interqual
  • Excellent time management and organizational skills with strong attention to detail and accuracy; the ability to prioritize, multi-task and meet deadlines is critical
  • Work hours of operation 9:30-6 EST to accommodate our 800 line
  • Adaptability/Flexibility in terms of schedule
  • Broad knowledge of the California Workers’ Compensation, insurance carrier and authorization referral processes
  • Monitor and ensure the patient’s access to the appropriate level of care, the right healthcare providers, and the correct setting and services to meet the patient’s needs, promoting coordination and continuity in the patient’s healthcare
  • One or more years of experience with medical office administration and/or workers’ compensation claim administration
  • Rarely kneel, crawl, reach/work above shoulder, twist/bend/stoop/squat, grasp lightly/fine manipulation, grasp forcefully, sort and file paperwork, carry, push, and pull objects that weigh 11-20 pounds
  • Perform detail-oriented work in a fast paced environment

Skills For Msw-case Management Specialist Resume

  • Be flexible with regard to process changes
  • The case management systems they use and how they link to other systems; the processes they follow; and the data that they maintain in order to ensure that their end users achieve effective use of the system; accurate data entry; adherence to data and data privacy standards; and excellent process adherence
  • First point of issue escalation for country Super users, perform analyses of the issue and identify correct course of action. Liaise with all appropriate stakeholders as necessary
  • Valid non-commercial California Driver’s License or willingness to obtain and maintain one
  • Liaise between country Superusers, ITS Global Solution team and third party technical support team for more complex or more technical issues
  • Localize test plans for system changes that impact the Americas service center, upgrades, patch enhancements and projects. Co-ordinate country level test requirements including identification of suitable employee data for testing, security/access to test systems etc. Manage test execution across countries ensuring timelines are adhered to
  • Identify gaps/weaknesses in super user/key user networks and work with stakeholders to address them
  • Manage system security/access requirements on behalf of countries supported. Liaise with global team for provision of security requirements and manage the periodic access review process for all user access within the countries supported

Skills For Conflict Free Case Management Specialist Resume

  • Work with the Case Management Region and Global Capability Leads, Global Service Line Leads and ITS Global Solution Owners to identify planned changes to systems and/or processes, ensuring that appropriate training plans are in place and are adequately resourced to support smooth introduction of changes
  • Provides appropriate information to patients, their families, physicians, health care professionals, and insurance carriers on the coverage and benefits of all Sanofi’s renal products
  • Point of contact for assigned sales region for reimbursement related questions related to Sanofi’s Renal products
  • Perform Verification of Benefits (VOBs) and claim confirmations for patients who are clinically appropriate for Sanofi’s Renal products
  • Proactively partner with Clinical Science Specialist to identify and address Renal Healthcare Professionals’ needs; identify where Renassist can contribute to, and support, individual business plan
  • Verifications for Sanofi’s Renal products in a timely manner
  • Provides appropriate information to patients, their families, physicians, health care professionals, and insurance carriers on the coverage and benefits of all Genzyme’s renal products

Skills For Case Management Specialist Msw-fsed Resume

  • Handles incoming calls through the claim toll free lines
  • Provides plan and claim information, assists with submission of claims and makes outbound calls to gather missing information on incomplete claims
  • Point of contact for assigned sales Zone for reimbursement related questions related to Genzyme’s Renal products
  • Verifications for Genzyme’s Renal products in a timely manner
  • Administers HINN’s (Hospital Issued Notices of Non-Coverage) as appropriate
  • Able to appropriately explain varying plan provisions to customers accurately and in a professional manner. Responds to telephone inquiries from insureds regarding specific claim details

Skills For Case Management Specialist Resume

  • Completes form letters, tasks and problem solve for resolution of customer issues
  • Contributes ideas that enhance service quality
  • Assist state agency representatives in marketing Self Direction to prospective Participants, family members, representatives, service providers, others through development, revision and distribution of program materials, and through individual and group presentations, home visits and telephone contacts
  • Explain the roles and responsibilities of self-direction to Participants and their appointed representatives, including the responsibilities of being an employer, hiring and supervising workers
  • Explain the roles and responsibilities of Public Partnerships in providing Financial Management services to Participants/representatives, including the responsibility for payroll processing and payment, and the responsibility for tax withholding and reporting
  • Explain the roles and responsibilities of Public Partnerships in providing Support Broker services to Participants/representatives, including the responsibility of assisting with the enrollment process and interfacing with the Participants DIDD Case Manager to meet the needs of the Participant related to Self-Direction

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