Carrie Thompson

Contract Client- The San Francisco Health Plan

• Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Provides advice, works cases and educates clients on whether their members are receiving the appropriate level of care at the appropriate time and location per evidenced based criteria. (Milliman, InterQual).
• Establishes and implements client approved process changes and education to enhance patient outcomes and reduce readmissions where possible.
• Performs all aspects of utilization review activities including pre-certification, initial, concurrent, retrospective review and denial management.
• Meets with the client to interpret external audit findings, corrective actions plan remediation and identify gaps in their current processes.

• Reviewed admissions for all lines of business to determine the correct level of care; discuss status changes with providers along with explanations of why the case is inpatient or observation based on evidenced based data from InterQual, Milliman and Medicare.
• Responsible for denial management with Commercial, and Medicaid payers. Produce appeals correspondence with payers; peer to peer scheduling. (overturn rate in 2021 was 96.3% with revenue recapture of 147,904 dollars).
• Maintained spreadsheets for tracking and trending length of stay and avoidable days which are presented to the finance department quarterly. (facility's length of stay was reduced 2.7 days per 1K admits in 2021).
• Collaborated with the Emergency Department staff and providers to create patient care plans with the (EDIE) Emergency Department Information Exchange program. Implementation of these assessments and education on social determinants and barriers resulted in a 66% reduction of readmissions in 2021.
• Participated in Interdisciplinary rounds daily in an efforts to ensure a 360 view of the patient and identify gaps in care between nursing, providers, physical and occupation therapy and dietary.
• Responsible for clinical documentation, Provider query's and coding of inpatient stays including behavioral health and substance abuse cases using the ChartWise program.

• Oversaw a staff of 13 utilization review nurses covering all lines of business in the state of Washington.
• Reviewed staff metrics to meet defined goals and targets set forth by the company.
• Gathered, documented and modeled data to assess business trends.
• Audited casework and provided feedback to the staff on critical thinking and documentation.
• Interacted with internal and external customers, patients and families.
• Represented the company in annual audits of Medicaid performance by the Washington state Healthcare Authority.
• Successfully remediated the corrective action plan United was on with the state health care authority in 2005 with continued compliance.
• Coordinated Medicare fast track appeals.
• Participated in policy and program development and implementation.
• Met or exceeded all regulatory and state specific requirements for turn around times and follow up care standards.
• Coordinated NCQA, HEDIS and URAC data collection and verification for onsite surveys in all Western state United Healthcare business segments.

Additional job while working at United Healthcare