Crystal Shumaker MSN, RN, CCM
Sherwood,AR
Summary
Seasoned Director of Utilization Management at Arkansas Blue Cross Blue Shield, adept in leading cross-functional teams to streamline healthcare processes and enhance service delivery. Excelled in implementing automation and technology integration, significantly improving operational efficiency and compliance within case management and utilization management departments. . Renowned for strategic leadership and fostering a high-performance culture, demonstrated by pioneering staffing solutions that bolstered nurse morale and operational effectiveness.
Overview
14
14
years of professional experience
Work History
Director of Utilization Management
Arkansas Blue Cross Blue Shield
Little Rock , AR
07.2022 - Current
- Lead and manage cross-functional teams of 100 + staff to optimize case and utilization management processes, ensuring high-quality service delivery.
- Oversee operational improvements that enhance documentation accuracy, workflow efficiency, and compliance with industry regulations.
- Implement automation initiatives, such as bots for record retrieval, reducing administrative workload.
- Developed staffing models that enhanced employee engagement and reduced operational costs, fostering a high-performance culture.
- Led implementation of a new documentation platform, enhancing standardization, accuracy, and efficiency across utilization management
- Improved turnaround times for case reviews, eliminating missed deadlines and ensuring compliance with regulatory standards
- Developed innovative staffing solutions, reducing reliance on external vendors by introducing strategic shift changes, improving nurse morale and operational efficiency
Manager of Clinical Support
Arkansas Blue Cross Blue Shield
Little Rock, AR
01.2015 - 07.2022
- Spearheaded team diversity and inclusion initiatives, fostering a high-trust culture with low turnover rates over nine years.
- Increased monthly referrals from 1,500 to 3,700 by streamlining workflow efficiencies.
- Implemented advanced technology solutions and automation reducing staff clicks and access points, enhancing productivity, and reducing administrative burden.
- Optimized clinical strategies and reduced financial risks by integrating gaps in care and performance guarantees (PGs) into national account algorithms.
- Led cross-training initiatives with 75 + team members, expanding nurse expertise to cover multiple lines of business, improving service delivery across customer service and case management and improve bed first- call resolution rates.
- Served as Clinical Lead for HealthShare, enhancing clinical documentation and data integration.
- National Speaker at the 2019 Blue Summit, presenting on the successful enhanced Gaps in Care program.
Director of Home Health Services
North Metro Home Health
Jacksonville , AR
01.2013 - 12.2014
- Maintained awareness of government regulations, health insurance changes and financing options.
- Ensured that all clinical documentation is completed accurately and submitted on time according to established guidelines.
- Managed and coordinated Home Health Services staff including hiring, training, evaluating performance and providing guidance.
- Collaborated with multi-disciplinary staff to improve overall patient care and response times.
- Monitored compliance of all state regulations related to Home Health Services.
- Developed and implemented policies and procedures for the Home Health Services department.
- Established relationships with local physicians, hospitals, nursing facilities, hospices and community agencies involved in home health services.
- Administered fiscal operations for accounting, budget planning, authorizing expenditures and coordinating reporting.
- Maintained communication and transparency with governing boards, department heads and medical staff.
- Coordinated implementation of new technology systems related to Home Health Services.
- Managed changes in integrated health care delivery systems and technological innovations while keeping focus on quality of care.
Regional Case Manager
Arkansas Blue Cross Blue Shield
Little Rock, AR
02.2011 - 12.2012
- Conducted initial assessments to determine patient eligibility for programs and services in community.
- Provided referrals to appropriate medical, mental health, and social services.
- Coordinated support services and optimized communication between healthcare workers and patients.
- National account coverage as a case manager.
- Negotiated rates for outpatient and inpatient facilities nationwide.
- Coordinated outpatient and transitions of care to lower and higher levels of care.
- Coordinated resources during patient transitions.
- Educated patients on self care.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
- Recognized by management for providing exceptional customer service.
Education
Master of Nursing Informatics -
American Sentinel University
Waterbury, CTBachelor of Nursing -
University of Arkansas for Medical Sciences
Little Rock, ARSkills
- Utilization & Case Management
- Compliance & Regulatory Oversight
- Operational Leadership & Team Management
- Clinical Workflow Optimization
- Risk Management & Quality Improvement
- Strategic Leadership & Change Management
- Automation & Technology Integration
- Healthcare Analytics & forecasting
Timeline
Director of Utilization Management
Arkansas Blue Cross Blue Shield
07.2022 - Current
Manager of Clinical Support
Arkansas Blue Cross Blue Shield
01.2015 - 07.2022
Director of Home Health Services
North Metro Home Health
01.2013 - 12.2014
Regional Case Manager
Arkansas Blue Cross Blue Shield
02.2011 - 12.2012
Master of Nursing Informatics -
American Sentinel University
Bachelor of Nursing -
University of Arkansas for Medical Sciences