ANTHONY GILVIN
EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER
DANVILLE,KY
9
years of professional experience
Experienced in utilization management and discharge planning, with strong skills in HIPAA compliance, clinical assessment, and communication. Proven ability to collaborate with healthcare providers to develop and implement effective care plans. Eager to leverage expertise to excel as an ONSITE BUSINESS SYSTEMS SPECIALIST.
Work History
ER CASE MANAGER / SOC. WORK/ DC PLANNER
1 Year 5 Months- Coordinated patient discharge planning and post-acute referrals to support safe transitions of care.
- Collaborated with physicians, nurses, and social workers to resolve barriers to timely patient placement.
- Reviewed medical necessity and utilization criteria to support appropriate levels of care.
- Communicated with insurance providers to secure authorizations and address coverage issues.
- Monitored patient progress and updated care plans to align services with changing needs.
- Documented case management interventions accurately in electronic health records.
- Educated patients and families on community resources, follow-up care, and discharge requirements.
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
- Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Enhanced communication between clients and providers through consistent follow-ups and progress updates.
- Achieved positive client outcomes by developing and implementing comprehensive case management plans.
- Advocated for client rights when interacting with external agencies or institutions, ensuring fair treatment at all times.
- Provided crisis intervention support for clients experiencing emergencies, using appropriate techniques to de-escalate situations safely.
- Contributed to team discussions and case conferences actively, sharing insights and expertise with colleagues to optimize client support strategies.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Developed and implemented comprehensive case management plans to address client needs and goals.
- Assisted clients in navigating housing, legal services and public benefits to gain access to valuable resources.
- Collaborated with multidisciplinary teams to address client needs and formulate tailored support strategies.
- Assisted clients in setting achievable goals while providing ongoing encouragement and support throughout the process of reaching those objectives.
- Coordinated essential services for clients, resulting in improved overall well-being and selfsufficiency.
- Fostered open lines of communication with clients'' families and support networks, involving them in the case management process as appropriate.
- Participated in regular professional development opportunities to stay current on best practices within the field of case management.
- Partnered with physicians, social workers, activity therapists, nutritionists, and case managers to develop and implement individualized care plans and documented patient interactions and interventions in electronic charting systems.
- Strengthened relationships with community organizations to increase access to supportive resources for clients in need.
- Promoted a safe environment for vulnerable populations by reporting suspected abuse or neglect.
- Reduced client wait times for service access by optimizing internal referral processes.
- Coordinated with healthcare providers to ensure clients had access to necessary medical services, enhancing their overall well-being.
- Collaborated with mental health professionals to address psychological needs of clients, supporting their holistic recovery.
- Developed partnerships with local agencies to provide broader range of services for clients, broadening their support network.
- Managed crisis situations with empathy and professionalism, ensuring client safety and continuity of care.
- Developed resource directory for clients, simplifying their search for essential services.
- Provided leadership, guidance and support to staff members.
UTILIZATION REVIEW SPECIALIST
3 Years 5 Months- Participated in team meetings providing updates on projects and identifying areas requiring further investigation or follow up action.
- Collaborated with providers to develop appropriate care plans for members and patients that meet their individual needs while optimizing resources available.
- Assisted in developing educational materials related to utilization management processes for internal staff and external partners.
- Adhered to all federal and state compliance requirements related to utilization review process.
- Assessed provider requests for authorization of services utilizing clinical judgement and evidence based guidelines.
- Maintained knowledge of current regulations governing healthcare reimbursement as well as changes in policy or procedure within organization or industry standards.
- Utilized critical thinking skills when evaluating complex cases involving multiple diagnoses or treatments.
- Conducted retrospective reviews of medical claims and other documentation to determine the appropriateness of services rendered by providers.
- Communicated effectively with internal departments, external vendors, providers, members and patients, payers and other stakeholders regarding utilization management issues.
- Performed utilization review activities, including pre-authorization and concurrent reviews of services to ensure that medical necessity criteria were met.
- Documented correct records of clinical treatment to minimize coding errors and denied claims.
CASE MGR /DISCHARGE PLANNER
9 Months- Participated in team meetings to discuss case management strategies for individual cases.
- Educated clients on available community resources and how to access them effectively.
- Assisted clients with obtaining basic needs such as housing, food, clothing, transportation, employment assistance and medical care.
- Maintained accurate records of client progress and documentation of all contacts with clients.
- Maintained clients' records by reviewing case notes and logging events and progress.
- Created individualized service plans in collaboration with clients, families, and other professionals.
- Demonstrated success in building relationships with clients and providing emotional support.
- Implemented case management plans, provided assessments, and offered counseling and support.
- Coordinated meetings between clients, family members and other health care providers involved in the treatment process.
- Met directly with patient to assess needs and develop individualized continuing care plan in collaboration with physician.
- Advocated for patients in healthcare or social service environments to promote wellness and autonomy.
- Developed comprehensive assessment plans to evaluate client needs and develop appropriate interventions.
- Evaluated client eligibility for government benefits or entitlements such as Social Security Disability Insurance.
- Provided advocacy services on behalf of clients when necessary.
- Adhered to legal requirements regarding confidentiality of information related to clients' cases.
- Collaborated closely with treatment teams to appropriately coordinate client care services.
- Conducted crisis intervention sessions with clients when needed.
- Facilitated referrals to community resources for support services including financial assistance programs.
- Collaborated with local agencies to provide comprehensive wrap-around services for at-risk youth populations.
- Prepared clients' discharge by reviewing and amplifying discharge plans and coordinating discharge and post-discharge requirements.
- Provided direct service and support to individuals and clients, such as handling referral for child advocacy issues, conducting needs evaluation, and resolving complaints.
- Consulted with agency staff and other community programs on program-related federal, state, and county regulations and policies.
UTILIZATION REVIEW SPECIALIST
2 Years 9 Months- SAME JOB DESCRIPTION AS THE FIRST JOB ON MY RESUME. I LEFT THIS POSITION TO TAKE THE CASE MGR. DISCHARGE PLANNER POSITION AT JAMES B. HAGGIN
MEDICAID ELIGIBILITY SPECIALIST
1 Year 9 Months- Researched benefits available through other agencies for individuals who are not eligible for Medicaid services.
- Reviewed Medicaid eligibility applications to determine financial and medical eligibility requirements.
- Facilitated enrollment processes for approved applicants by submitting appropriate documentation in a timely manner.
- Interpreted state laws, rules, regulations and policies related to Medicaid programs.
- Analyzed complex cases involving multiple family members or special circumstances such as disabilities or long-term care needs.
- Communicated effectively with clients via phone calls, emails or face-to-face meetings to explain program requirements and answer questions.
- Identified discrepancies or inconsistencies in documents submitted by clients and requested additional evidence as needed.
- Verified income levels, assets and other pertinent information from a variety of sources including tax returns, pay stubs, bank statements and Social Security documents.
- Processed renewal applications promptly upon receipt in order to prevent lapse in coverage for existing beneficiaries.
- Maintained up-to-date knowledge of changing federal and state regulations governing Medicaid programs.
- Conducted detailed interviews with applicants to assess their needs and provided assistance in completing application forms.
- Performed data entry into the computer system accurately and efficiently to ensure timely processing of applications.
- Explained program requirements in detail to potential participants and answered their questions about the application process.
- Answered applicants' questions about benefits and claim procedures.
- Developed a working knowledge of all relevant state and federal laws governing public assistance programs.
- Checked with employers and other references to verify answers and obtained further information.
- CONTRACTOR POSITION LOCATED AT EPHRAIM MCDOWELL
Education
BACHELOR OF SCIENCE (B.S.) - DISPUTE RESOLUTION AND CONFLICT MANAGEMENT
- Relevant Coursework
- INTERVIEWING
- POSITIVE DISPUTE RESOLUTION
- MEDIATION
- GPA: 3.25
Skills
HIPAA compliance
Medicare compliance
Private insurance policies
Medicaid compliance
Insurance verification
Medicaid
Discharge planning
Needs assessment
Medicare
Quality improvement
Utilization management
Medical necessity criteria
Clinical assessment
Documentation and reporting
Interpersonal and written communication
Utilization review
Plan of care support
Communication
In depth knowledge of our internal computer platform
Timeline
ER CASE MANAGER / SOC. WORK/ DC PLANNER
EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER
06.2025 - CurrentRead More
UTILIZATION REVIEW SPECIALIST
EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER
01.2023 - 06.2026Read More
CASE MGR /DISCHARGE PLANNER
EPHRAIM MCDOWELL /JAMES B. HAGGIN MEDICAL CENTER
04.2022 - 01.2023Read More
UTILIZATION REVIEW SPECIALIST
EPHRAIM MCDOWELL REGIONAL MEDICAL CENTER
07.2019 - 04.2022Read More
MEDICAID ELIGIBILITY SPECIALIST
ALORICA
10.2017 - 07.2019Read More
Eastern Kentucky University
BACHELOR OF SCIENCE (B.S.) from DISPUTE RESOLUTION AND CONFLICT MANAGEMENT
Read More
REFERENCES
- Kim Maxey MSN, RN. Trauma Program Manager
kjmaxey@emhealth.org
859-239-1109
Jennifer Trisler RN, ER Dept. Facilitator
jntrisler@emhealth.org
859-239-1128
Sara Patterson BSN, RN ER Dept. Unit Facilitator, Trauma PI Coordinator
spatterson@emhealth.org
859-239-1108
Personal Information
Title: ED / BMU DISCHARGE PLANNER