Gwen Archinal
Massillon,OH
Summary
Clinical professional with solid foundation in clinical analysis and keen eye for detail. Adept at optimizing clinical workflows and ensuring compliance with regulatory standards. Highly collaborative team player with focus on achieving impactful results and adapting to evolving healthcare needs. Proficient in using advanced clinical software and methodologies to support data-driven decision-making.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Senior Clinical Analyst
Optum Financial
01.2023 - Current
- Improved patient risk assessment accuracy by analyzing medical records and evaluating health histories
- Managed relationships with key stakeholders such as brokers, agents, and providers to ensure smooth workflow execution and client satisfaction.
- Collaborated with sales teams to provide accurate quotes, ensuring customer satisfaction and retention.
- Conducted thorough investigations of potential fraud cases to protect company assets and maintain the integrity of the underwriting process.
- Utilized knowledge of insurance principles, policies and procedures to make decisions on risk assessment.
- Analyzed data to identify trends and predict future insurance needs.
Utilization Management Nurse /Medical Claim Review
United Healthcare
01.2010 - 01.2023
- Deliver a high-level of clinical operations, covering utilization review for prior authorization and retrospective case review
- Conduct reviews and provide feedback on claims and audits applying Milliman Care & InterQual guidelines and ensuring compliance with NCQA, state, and federal regulations
- Reduced hospital readmissions through effective discharge planning and coordination of post-discharge care.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Ensured compliance with regulatory guidelines by staying current on industry standards and participating in ongoing education opportunities.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
Utilization Management Nurse
McBee Associates Inc.(AKA Netsmart)
09.2016 - 04.2020
- Performed admission reviews based for medical necessity based upon Interqual and/or Milliman specification.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Applied critical thinking skills to assess complex medical cases and determine appropriate levels of care in accordance with industry benchmarks.
Utilization Management Nurse
Mercy Medical Center, Inpatient Acute Care
01.2007 - 01.2014
- Facilitated communication between healthcare providers, patients, families, and insurance carriers to optimize outcomes.
- Maintained up-to-date knowledge of payer-specific guidelines to ensure accurate authorizations for medically necessary services.
- Applied critical thinking skills to assess complex medical cases and determine appropriate levels of care in accordance with industry benchmarks.
- Reduced hospital readmissions through effective discharge planning and coordination of post-discharge care.
- Utilized Interqual and Milliman Care guidelines and developed competency through continued education
- Composed and developed appeals for managed care denial claims, delivering strategic methods to improve process activities
Case Manager
AultCare
01.2003 - 01.2007
- Executed strategic management of enrollees with complex needs, including chronic conditions and transplant services by delivering telephone-based services
- Performed assessment, review, utilization management, and concurrent review while ensuring activities were individualized and patient-focused with specific attention given to disease management and education
- Collaborated with committee members on employer group enrollment evaluation to address care management and implement improvement initiatives, covering transition and retrieval of care to network providers, rate negotiation, and obstacles to planned treatment
Case Manager
Anthem Blue Cross Shield
09.1998 - 10.2003
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Coordinated with healthcare providers to ensure clients had access to necessary medical services, enhancing their overall well-being.
- Conducted thorough assessments to identify client needs, laying groundwork for effective case management.
Education
Bachelor of Science (BS) - Nursing
University of Akron
Akron, OHSkills
- Medicare & Medicaid
- Regulatory Compliance
- Appeals Processes
- Interqual
- Milliman Care Guidelines
- Clinical Documentation
- Disease Management
- Microsoft Word and Excel
- Healthcare regulations
- Managed care
- Home health care
- Utilization management
- Compliance procedures
- Case management
- Multitasking
- Electronic Health Records
- ICD-10
Certification
Certified Case Manager, Commission for Case Manager Certification
Personal Information
Title: Senior-Level Clinical Analyst
Timeline
Senior Clinical Analyst
Optum Financial
01.2023 - Current
Utilization Management Nurse
McBee Associates Inc.(AKA Netsmart)
09.2016 - 04.2020
Utilization Management Nurse /Medical Claim Review
United Healthcare
01.2010 - 01.2023
Utilization Management Nurse
Mercy Medical Center, Inpatient Acute Care
01.2007 - 01.2014
Case Manager
AultCare
01.2003 - 01.2007
Case Manager
Anthem Blue Cross Shield
09.1998 - 10.2003
Bachelor of Science (BS) - Nursing
University of Akron
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