Janette Marie Jones
North Palm Beach,FL
Summary
Dedicated and experienced professional with a comprehensive background in healthcare management, utilization review, and clinical coordination. Proven expertise in conducting assessments, ensuring compliance with medical criteria and accreditation standards, and providing education and support to clients and stakeholders. Skilled in documentation, trend analysis, and quality management. Strong communicator and team player with a commitment to delivering high-quality care and improving patient outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Clinical Care Consultant
Navigator Health
09.2022 - Current
- Maintained strict confidentiality of client information in accordance with HIPAA regulations and professional ethical standards.
- Documented clinical notes accurately and promptly, maintaining thorough records.
- Educated clients on addiction triggers and coping strategies, empowering them to make informed choices for their recovery journey.
- Leveraged motivational interviewing techniques to help member's identify personal motivations for change and increasing member's motivation to attend treatment.
- Provided crisis intervention services when necessary to address immediate concerns related to substance abuse or co-occurring mental health issues.
- Conducted thorough intake assessments to determine appropriateness of treatment options and assisted with making first appointment for member.
- Coordinated care with other professionals to provide clients with comprehensive support.
- Supported aftercare planning for continued recovery after treatment.
- Education provided to family members seeking guidance on how to help a loved one struggling with addiction
- Handled escalated calls professionally, effectively resolving complex issues and ensuring client satisfaction at all times.
- Enhanced customer satisfaction by efficiently addressing and resolving inquiries in a timely manner.
- Provided appropriate referrals to community-based resources for callers seeking additional support or services.
- Improved caller experience by providing empathetic listening and support during crisis situations.
- Managed high-stress calls effectively, utilizing active listening and problem-solving skills.
- Assisted in the development of training materials for new Clinical Care Consultants, ensuring consistency in service delivery.
Utilization Review Specialist
Wayside House
10.2020 - Current
- Demonstrated strong analytical skills by interpreting complex medical records and synthesizing relevant information for utilization review purposes.
- Ensured accuracy of billing and reimbursement processes by reviewing medical records for proper coding and documentation practices.
- Maintained regulatory compliance by staying updated on industry standards and guidelines, implementing changes when necessary.
- Maintained strict confidentiality of patient information, adhering to HIPAA regulations and organizational policies regarding privacy and data security.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed prior authorization review of services requiring notification.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals via appeal request.
- Performed admission reviews based for medical necessity based upon ASAM, CALOCUS, LOCUS, and multiple carriers Medical Necessity specification.
Utilization Management Behavioral Health
Lucet Health
12.2017 - 04.2024
- Managed complex cases involving, expertly navigating sensitive situations while maintaining a focus on patient outcomes.
- Optimized the delivery of healthcare services by staying current on emerging trends and developments in the field of utilization management.
- Assisted in the development of targeted strategies aimed at reducing unnecessary service usage without compromising quality of care.
- Developed strong working relationships with healthcare providers to ensure seamless communication and coordination of services.
- Served as a liaison between patients, healthcare providers, and insurance company to facilitate timely approvals of necessary treatments.
- Reduced wait times for essential services by effectively managing utilization review caseloads and prioritizing urgent requests.
- Enhanced patient satisfaction by promptly addressing inquiries regarding coverage decisions and available resources.
- Proactively identified potential barriers to effective service delivery, working closely with clinical teams to address issues before they impacted patient outcomes.
- Improved patient care management by efficiently coordinating and monitoring medical services.
- Conducted thorough reviews of medical records, ensuring compliance with regulatory requirements and industry standards.
- Maintained up-to-date knowledge on relevant health policies, regulations, and industry best practices through ongoing professional development opportunities.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
- Submitted verbal and written notification to members and providers.
- Provided exceptional customer service when interacting with individuals involved in each appeal or grievance situation, demonstrating empathy and professionalism at all times.
- Actively participated in quality improvement initiatives aimed at enhancing the overall member experience within the organization''s healthcare services offerings.
- Reduced turnaround times for case resolutions by effectively prioritizing workload based on urgency levels designated by regulatory standards.
- Demonstrated high-level attention to detail when reviewing medical records, provider contracts, and other relevant documents during case assessments.
- Ensured timely submission of required reports to regulatory agencies by diligently monitoring deadlines and maintaining accurate records.
Behavioral Analysis
Monarch Behavior Analysis
06.2017 - 12.2017
- Administered therapy and applied behavioral analysis techniques in school, home and community to facilitate client treatment plan.
- Incorporated play-based therapy into sessions, increasing motivation while targeting relevant skill development areas such as communication or social cognition.
- Established trusting relationships with clients and their families, fostering a supportive environment conducive to growth and learning.
- Enhanced parent involvement by conducting regular meetings and providing resources for continued success outside therapy sessions.
- Supported clients'' transitions between educational settings by working closely with schools to develop appropriate accommodations and modifications based on individual needs.
- Maintained accurate documentation of client progress, ensuring compliance with regulatory requirements and facilitating effective communication among team members.
- Conducted thorough assessments of client needs, developing tailored intervention strategies based on findings.
- Assisted clients in achieving goals by utilizing reinforcement systems, shaping techniques, and prompting strategies tailored to individual learning styles.
- Developed individualized treatment plans for clients, addressing specific behavioral concerns and goals.
- Implemented data-driven strategies to monitor client progress, adjusting interventions as needed for optimal results.
- Adapted therapeutic approaches according to each client''s unique preferences, strengths, challenges, allowing greater engagement and progress.
- Provided ongoing support and guidance to parents, empowering them to effectively implement ABA techniques at home.
- Evaluated client progress during quarterly review meetings, making necessary adjustments to treatment plans and celebrating achievements alongside families.
- Collaborated with interdisciplinary teams to ensure comprehensive care and support for clients and their families.
- Implemented behavior intervention plans, increasing positive behaviors and reduce challenging behaviors.
- Monitored and documented client progress using data collection techniques.
Utilization Review Specialist
Mandala Healing Center
02.2013 - 06.2017
- Demonstrated strong analytical skills by interpreting complex medical records and synthesizing relevant information for utilization review purposes.
- Ensured accuracy of billing and reimbursement processes by reviewing medical records for proper coding and documentation practices.
- Maintained regulatory compliance by staying updated on industry standards and guidelines, implementing changes when necessary.
- Maintained strict confidentiality of patient information, adhering to HIPAA regulations and organizational policies regarding privacy and data security.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed prior authorization review of services requiring notification.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals via appeal request.
- Performed admission reviews based for medical necessity based upon ASAM, CALOCUS, LOCUS, and multiple carriers Medical Necessity specification.
Education
Master of Arts - Mental Health Counseling
Webster University
St Louis, MO06.2006
Master of Arts - Behavioral Sciences
Barry University
Palm Beach Gardens, FL 06.2004
Skills
- Problem-Solving
- Attention to Detail
- Team Leadership & Development
- Client Relationships
- MS Office
- Issue Resolution
- Assessments
Certification
- Licensed Mental Health Counselor - MH10026
- EMDR Trained
Timeline
Clinical Care Consultant
Navigator Health
09.2022 - Current
Utilization Review Specialist
Wayside House
10.2020 - Current
Utilization Management Behavioral Health
Lucet Health
12.2017 - 04.2024
Behavioral Analysis
Monarch Behavior Analysis
06.2017 - 12.2017
Utilization Review Specialist
Mandala Healing Center
02.2013 - 06.2017
Master of Arts - Mental Health Counseling
Webster University
Master of Arts - Behavioral Sciences
Barry University
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