Alexandra Haley
Covington,LA
Summary
- Performance oriented clinician with over 10 years of successful experience in the hospital, outpatient, and insurance settings.
- Demonstrated ability of applying clinical knowledge to identify barriers and improve outcomes related to appropriate utilization of services.
- Recognized consistently for performance excellence and establishing and maintaining productive work environments and relationships.
Overview
11
11
years of professional experience
Work History
Utilization Management Behavioral Health Professional 2
Humana
Metairie, LA
07.2024 - Current
- Conducts comprehensive clinical reviews for Louisiana Medicaid, maintaining compliance with turnaround times and medical necessity criteria.
- Served as SME for PSH authorizations and point of contact for LDH for PSH, responsible for updating UM eligibility reports and submitting necessary criteria to LDH.
- Supported cost-savings initiatives such as cross-market training preceptor.
- Trained and mentored new associates on clinical reviews, medical necessity criteria, procedures, and electronic systems.
- Maintains a positive relationship with providers to ensure necessary clinical documentation is received and to coordinate member needs.
- Actively works with Case Management through referrals to ensure members are connected with additional needed services outside of current provider and resources to close gaps.
- Consistently maintains compliance with turnaround time performance and audit scores.
Care Navigator
Peoples Health
Metairie, LA
12.2014 - 06.2024
- Initiated STAR/HEDIS project that included assessing members to improve member outcomes. This initiative lead to innovative programs that increased appropriate referrals, increased Comprehensive Wellness Assessment scheduling, improved outcomes and tracked trends in data.
- Worked with management on process optimization and opportunities for efficiency.
- Created training presentations for clinical staff, providing education on the Social Determinants of Health.
- Subject matter expert in EQ Suites System and trainer for clinical staff on program.
- Championed a new Social Determinants of Health Assessment used by social workers in multiple hospitals to evaluate members in the hospital setting to determine discharge planning needs.
- Connected Medicare and D-SNP members with resources to resolve disparities to ensure compliance with care and prevent unnecessary hospitalizations, addressing Social Determinants of Health.
- Interacted with members and the multidisciplinary team to establish measurable health goals, prioritize member needs, monitor member adherence to the plan of care, and identify barriers to care.
- Maintained relationships with providers to coordinate care based on member needs, reduce gaps in care, and reduce rehospitalizations.
- Collaborated with RN on case management to resolve disparities by linking members to resources and empowering them to be active in their health to promote positive outcomes.
- Conducted comprehensive Health Risk Assessments and formulates plans of care with specific focus on D-SNP.
- Utilized EMR systems, including EQ Suites and EPIC, for documentation and care coordination purposes.
Education
Bachelor of Science - Psychology
Louisiana State University And A&M College
Baton Rouge, LA12-2010
Master of Social Work -
Louisiana State University And A&M College
Baton Rouge, LA05-2013
Master of Healthcare Administration -
Louisiana State University At Shreveport
Shreveport, LA05-2021
Skills
- Utilization Management
- LA Clinical Coverage Policies
- MCG
- ASAM
- Social Determinants of Health
- D-SNP Programs
- HEDIS and Star Measures
- Case Management
Timeline
Utilization Management Behavioral Health Professional 2
Humana
07.2024 - Current
Care Navigator
Peoples Health
12.2014 - 06.2024
Bachelor of Science - Psychology
Louisiana State University And A&M College
Master of Social Work -
Louisiana State University And A&M College
Master of Healthcare Administration -
Louisiana State University At Shreveport