Jennifer Sweeney

• Responsible for ensuring adherence to all regulatory and compliance standards for utilization management department
• Accountable for drafting Utilization Management (UM) program description, conducting UM program evaluations, formulating UM work plans, and preparing other annual regulatory reports
• Presented thorough reports and updates, integrating details on Utilization Management (UM) initiatives, to workgroups, advancing through to executive-level committees
• Managed delegation oversight for Utilization Management department, overseeing quarterly case reviews, collecting and reporting on turnaround times, and conducting audits
• Conducted annual review and updates of utilization management policies and procedures
• Established strong relationships with key stakeholders within health plans organization and external delegated entities to ensure effective collaboration and alignment of objectives
• Developed workflows and processes for inpatient utilization management team.

Directed theUtilization Management department, encompassing intake, prior authorization, and quality assurance processes

• Functioned as subject matter expert, offering program guidance on utilization management functions and departmental operations
• Managed vision care benefits and medical management for members across various insurance plans, including Medicare, Medicaid, Children's Health Insurance Plan, and commercial insurance
• Offered leadership and guidance to remote team of direct reports, ensuring comprehensive compliance throughout intake, medical/benefit review, and notification processes, while upholding exceptional quality standards and customer service for members, providers, and clients
• Conducted analysis, interpretation, education, and updates to internal policies to align with and uphold adherence to all NCQA standards, federal regulations, and all laws outlined by 40+ states where business was held
• Orchestrated audits and mock audits, furnishing constructive feedback to team members and implementing robust quality improvement protocols to ensure utmost compliance standards while applying most medically appropriate care
• Provided routine analytics and ad hoc reporting to senior leadership, offering a comprehensive overview of departmental operations status and risk/risk mitigation strategies.

Managed and led Utilization Management Inpatient, Neonatal Intensive care unit, and skilled nursing facility prior authorization process, acting as a subject matter expert and providing guidance related to utilization management functions and departmental operations

• Members served held coverage by Medicare, Medicaid, USFHP, or Employee Health Plan (EHP)
• Orchestrated meticulous utilization management policies, processes, and procedures, intricately tailored to meet necessary standards of NCQA accreditation
• Directed and provided leadership to diverse remote team members including three nurse supervisors and 38 clinical nurse reviewers within utilization management department, ensuring both direct and indirect subordinates operated with highest level of performance, accountability, and quality review standards
• Provided nuanced analysis, strategic guidance, and instructive mentorship for refining internal policies to align seamlessly with regulatory mandates
• Applied astute interpretation of state and federal regulatory policies to optimize daily operational protocols
• Fostered close collaboration with reporting teams to ensure accuracy and punctuality of essential quality reporting
• Established sophisticated tracking mechanisms to monitor program progression post-process implementation
• Conducted meticulous evaluations of departmental performance, articulating findings and risks and prescribing refined process enhancements
• Crafted judicious Utilization Management responses to regulatory audits and formulated corrective action plans
• Presented reports on daily operations performance, quality metrics, and productivity, with tailored recommendations for adjustments
• Leveraged expertise in health insurance dynamics to fortify clinical nurses' adherence to regulatory mandates
• Managed denial correspondence rigorously, ensuring compliance with accrediting agencies and state regulatory frameworks
• Engaged in collaborative discourse with clients on clinical matters, navigating resolution processes adeptly
• Conducted rigorous data collation, trend analysis, and presentations to inform daily operations and improvement strategies
• Identified operational bottlenecks and proffered solutions to uphold compliance standards and operational fluidity
• Orchestrated development of Concurrent Review and Post-Acute medical management programs
• Championed quality objectives in alignment with regulatory and corporate imperatives
• Directed staff audit processes and conducted interrater reliability testing
• Monitored Prior Authorization program, evaluating effectiveness and mitigating potential barriers.

• Provided leadership and support to 20 concurrent review clinical nurses who managed acute and post-acute settings review for Medicare, Medicaid, USFHP, and EHP members
• Management and oversight of day-to-day operations of Utilization Management Department
• Provided training and education to new hires and training and reeducation to existing team members to include feedback and support.

• Conducted prior authorization review for outpatient services, including surgical, durable medical equipment, home health, genetic testing, fertility treatments, rehabilitation, and radiology services
• Precepted new hires, responsible for training in outpatient utilization management role
• Analyzed and applied strict adherence to policies and procedures to support medical necessity review for outpatient services
• Interpreted and applied regulatory state and federal policies to daily processes to maintain highest level of quality
• Suggested modifications to current policies and procedures to assist with application.

• Directed and managed catastrophic care and/or chronic illness or injury through total case management for average caseload of 85-105 patients
• Initiated contact with at-risk patients to complete comprehensive health and lifestyle assessment to determine potential knowledge deficits and current physical functioning, acuity, stability, and compliance
• Assisted in coordinating placement for substance abuse patient in inpatient facilities, intense outpatient facilities, group therapy
• Initiated communication with providers to obtain clinical records and treatment plan information and identify possible treatment issues or other care needs
• Assessed patient's current vocational/occupational functioning and identified any necessary modifications or accommodations while supporting patient with education to assist patient in achieving optimal vocational placement and functioning
• Developed care plans with achievable long and short-term goals for each case
• Provided education and support to patients regarding their disease process, co-morbidities, medications, treatment options, lifestyle modifications, and possible alternative treatments
• Documented all pertinent communications into computer system thoroughly, accurately, and promptly
• Performed and documented Utilization Reviews for various levels of care in accordance with plan layout using MCG guidelines
• Made medical necessity recommendations for type and duration of treatment using approved, evidence-based criteria or standards of care
• Identified and documented clinically appropriate treatment options to recommend most effective level of care regarding clinical complexity, patient and client needs, and benefit structure
• Coordinated cost-effective alternative care or provided intensive education/support to enhance quality of life and quality of care.