Jamie Turner
Nashville,United States
Summary
Driven by a passion for behavioral health, I leverage my expertise in utilization review and case management to enhance patient care. Skilled in medical necessity criteria and co-occurring disorders, I consistently ensured optimal health outcomes, demonstrating a profound ability to navigate complex cases with empathy and precision.
Overview
14
14
years of professional experience
1
1
Certification
Work History
BH Care Manager Utilization Review
Elevance Health
10.2022 - Current
- Managed psychiatric and substance abuse facility-based and outpatient programs through comprehensive telephonic and written reviews.
- Referred cases to Peer Reviewers as appropriate to ensure thorough evaluation and adherence to best practices.
- Applied appropriate screening criteria and clinical judgment to facilitate access to medically necessary, high-quality behavioral healthcare. - Utilized ASAM (American Society of Addiction Medicine), INTERQUAL, and MCG (Milliman Care Guidelines) criteria to inform clinical decision-making processes.
- Collaborated with medical directors in a team setting to staff complex cases, assisting in clinical determinations and care strategies.
BH Utilization Review Care Manager
Humana
03.2020 - 09.2022
- Conducted pre-certification and concurrent telephonic reviews with facilities for IP, RTC, PHP, and IOP levels of care.
- Working with Medicaid, Medicare, and commercially insured facilities, specializing in both mental health and substance use disorder treatment.
- Utilized MCG and ASAM criteria to make informed medical necessity determinations.
- Assessed and coordinated discharge planning in collaboration with case management and care coordination departments to ensure seamless transitions for clients.
- Participated in medical rounds to staff complex cases with medical directors, contributing to clinical decision-making processes.
- Referred cases to peer review when needed.
Behavioral Health Case Manager
Blue Cross Blue Shield
09.2019 - 03.2020
- Managed a caseload of members with complex behavioral health needs, providing tailored support and guidance.
- Completed thorough assessments to highlight members' most critical behavioral and physical health needs, creating targeted care plans to address these areas.
- Developed comprehensive treatment plans of care to assist patients in reducing barriers and achieving optimal health outcomes.
- Responded to crisis calls on the crisis line, connecting members with essential resources to resolve immediate crises effectively.
- Presented complex cases in a team meeting setting.
Utilization Review Specialist
Journey Pure
05.2017 - 09.2019
- Completed pre-certification and continued stay insurance reviews for all levels of care at a substance abuse treatment center
- Reviewed all clinical data to determine the most appropriate level of care for patients, utilizing medical necessity guidelines.
- Documented all insurance reviews and outcomes in the patient's EMR.
- Educated counseling staff regarding the documentation needed to demonstrate medical necessity.
- Initiated and scheduled peer reviews and expedited appeals.
Utilization Review Specialist
The Ranch
11.2016 - 05.2017
- Completing comprehensive biopsychosocial assessments for clients admitting to the Detox, RTC, PHP, and IOP levels of care at a co-occurring treatment facility.
- Conducting pre-certification and concurrent reviews with payers and level of care chart reviews.
- Coordinating peer reviews with medical directors.
- Attending and participating in treatment team meetings.
- Utilizing medical necessity and ASAM guidelines to determine the level of care most appropriate for patients.
- Collaborated with interdisciplinary teams to create effective discharge plans that promoted optimal patient outcomes while minimizing readmissions.
Intake Therapist
The Next Door
10.2013 - 10.2016
- Completed intake psychosocial assessments with clients, utilizing ASAM criteria to determine appropriate levels of care.
- Coordinated pre-certification and concurrent review requests with Managed Care Organizations (MCOs) to ensure timely access to services.
- Communicated effectively with referral sources to gather collateral information necessary for grant approvals, while maintaining professional working relationships.
- Conducted ongoing utilization reviews across all levels of care to ensure compliance and optimize resource allocation.
Transitional Living Therapist
Youth Villages
10.2010 - 10.2013
- Provided mental health counseling and case management services to young adults transitioning out of DCS custody and foster care, fostering their emotional and psychological well-being.
- Responded to client crisis events by implementing effective safety plans, ensuring immediate support and intervention.
- Developed and constructed individualized treatment plans tailored to each client's unique needs and goals.
- Completed comprehensive assessments, including biopsychosocial, strengths and needs, and independent living skills assessments.
- Facilitated referrals to community resources, including behavioral health, physical health, employment and educational assistance programs.
Education
Master of Arts - Clinical Professional Psychology
Roosevelt University
Bachelor of Arts - Psychology
Auburn University
Auburn, ALSkills
- Utilization Review
- Case Management
- Knowledge of medical necessity criteria
- Managed Care Organization experience
- Extensive ICD-10 understanding
- Experience working in co-occurring treatment facilities
Personal Information
Title: Mental Health Professional
Certification
- Licensed Professional Counselor in the state of Tennessee since 2016.
Timeline
BH Care Manager Utilization Review
Elevance Health
10.2022 - Current
BH Utilization Review Care Manager
Humana
03.2020 - 09.2022
Behavioral Health Case Manager
Blue Cross Blue Shield
09.2019 - 03.2020
Utilization Review Specialist
Journey Pure
05.2017 - 09.2019
Utilization Review Specialist
The Ranch
11.2016 - 05.2017
Intake Therapist
The Next Door
10.2013 - 10.2016
Transitional Living Therapist
Youth Villages
10.2010 - 10.2013
Master of Arts - Clinical Professional Psychology
Roosevelt University
Bachelor of Arts - Psychology
Auburn University
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