Candace Catherine Jarjosa
Southfield
Overview
9
9
years of professional experience
1
1
Certification
Work History
Utilization Review Specialist
Coronis Health
04.2024 - 10.2024
- Managed authorization of treatment for various substance abuse treatment facilities utilizing ASAM criteria and medical necessity criteria.
- Acted as a liaison between insurance companies and facilities to advocate for treatment for clients.
- Managed a high caseload of an average of 20 cases per day while maintaining quality.
- Developed and maintained strong collaborative working relationships with external insurance payers and facilities.
Manager - Clinical, Utilization Management
Centene Corporation/Meridian Health Plan
08.2020 - 05.2022
- Oversaw and supported a company acquisition by providing strategic direction to a high-performing team, working with various internal departments to ensure a seamless integration of new processes, and maintaining positivity and team cohesion through a transitional period
- Enforced Medicare, Medicaid, and utilization management practices, policies, and contractual agreements and managed cross-functional department collaboration to support goals and improve processes
- Assigned tasks and prioritized and delegated responsibilities to ensure efficient workflows and monitor departmental performance
- Conducted regular data analyses to identify opportunities, monitor trends, and improve utilization management metrics
- Improved employee engagement scores by 20% by developing trusting relationships with staff and ensuring concerns were actively listened to and addressed
Utilization Reviewer - Behavioral Health
Centene Corporation/Meridian Health Plan
10.2018 - 08.2020
- Applied clinical judgment to behavioral health authorization requests utilizing Interqual and ASAM to guide the clinical determination process and rendered determinations within 24 hours in compliance with state, accreditation, and department regulations
- Developed strong relationships with internal and external staff, managed a caseload of 25-30 cases per day exceeding production requirements of 15 cases per day, and maintained audit scores of 99-100%
- Initiated and managed projects to enhance team processes including the turnaround time (TAT) report, to support cross-functional collaboration for departmental support, and to proactively develop and communicate efficient processes to leadership
Behavioral Health Clinical Care Coordinator
Meridian Health Plan
05.2017 - 10.2018
- Facilitated discharge planning and coordinated with external healthcare team members to support the social needs of members to reduce readmission
- Collaborated with team members to identify cases requiring higher needs and utilized clinical skills and background to ensure member needs were supported
- Managed and maintained an organized caseload of members with complex needs to ensure timeliness, compliance, and appropriate member contact and follow-up
Care Coordinator Social Worker
Meridian Health Plan
02.2016 - 05.2017
- Supported person-centered planning, monitored and updated care plans, and coordinated care transitions within compliance time frames
- Assessed clinical risk and needs by administering health care assessments to determine needs, assist with connection to appropriate mental health services, and addressing barriers to care
- Led the Integrated Care Team to develop comprehensive care plans where member needs and goals were addressed
Education
Master of Arts - Social Work
University of Michigan
Ann Arbor, MI01.2014
Bachelor of Arts -
Michigan State University
East Lansing, MI01.2008
Certification
Licensed Master Social Worker (LMSW), #6801098862, 01/18
Timeline
Utilization Review Specialist
Coronis Health
04.2024 - 10.2024
Manager - Clinical, Utilization Management
Centene Corporation/Meridian Health Plan
08.2020 - 05.2022
Utilization Reviewer - Behavioral Health
Centene Corporation/Meridian Health Plan
10.2018 - 08.2020
Behavioral Health Clinical Care Coordinator
Meridian Health Plan
05.2017 - 10.2018
Care Coordinator Social Worker
Meridian Health Plan
02.2016 - 05.2017
Bachelor of Arts -
Michigan State University
Master of Arts - Social Work
University of Michigan
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