Linda B Cooper

Provide utilization review for Institutional Special Needs Plans(ISNP)/Medicare. Reviews clinical documentation for medical necessity with use of InterQual and Centers for Medicare & Medicaid Services (CMS) criteria. The utilization review process is conducted for outpatient /inpatient surgeries ,procedures, Durable Medical Equipment (DME), ambulance transport, Occupational, Speech, Physical Therapy , Home Healthcare, Wound Care, Out of network office visits, RX Injections and IV infusions . Liaison for the care team (Nurse Practicer, Case Manager, Social Worker ,Nursing Home Administrator and Physician) at the nursing home facilities working in collaboration with them to ensure the members prior authorizations are submitted with all the clinical documentation necessary to facilitate and complete the prior authorization process. Referrals made to the Medical Director for a determination of authorization request which do not meet the IQ and CMS Criteria. Developed and implement work processes which increase productivity and improve time management. Provide education to providers and nursing home care team as it relates to the prior authorization process and benefits available via the CMS.

Provided utilization review for Medicaid Star Plus managed Care Program. Clinical records reviewed for medical necessity with use of InterQual criteria for Outpatient services, Inpatient admissions, Concurrent review ,Skilled Nursing Facilities (SNF),Acute Rehabilitation and Long term care facilities(LTAC). Referred to the Medical Director review authorization request which did not meet InterQual criteria. Referrals made for Case Management and Behavioral Health services. Collaborated with the utilization review team in a weekly meeting to facilitate discharge planning and find solutions to barriers of discharge.

Worked with physicians and Multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge. Ensured patient progression towards desired outcomes by continuous monitoring patient care through assessments and/ or evaluations. Assessment and response to patient/family needs by coordinating efforts of other team members. Barriers were identified and resolved that would hinder effective patient care.

Collected and reviewed denial clinical information to formulate appeals, sending appeal correspondence and essential documentation to appropriate insurance carriers. Performed patient account research to prevent billing denials, worked with various departments as needed. Analyzed final claim denials to determine internal weaknesses in the organization and assist in developing action plans to avoid future denials. Developed reports/feedback to be presented to Denials Management team and Monthly Committee denials meetings. Assisted as needed with char audits,comparing the medical record against the patient's itemized bill to ensure complete and accurate charge captured. Completed special projects as identified and needed. Performed other duties as assigned.

Case Manager for specific client population initiating a collaborative process which assessed,planned, implemented,coordinated,monitored and evaluated the options and services required to meet an individual's health needs, utilized plan benefits and community resources. Available resources were used to promote quality and cost effective outcomes to benefit the members. As a Case Management Supervisor I coordinated and worked with Case mangers and Pre-Cert Nurses to establish efficient processes, work flows and assessed the level of of staffing available to respond to daily needs. This role worked closely with the Medical Affairs Manager, Medical Affairs Director and Medical Director for the implementation of medical Management programs across all lines of business.

Performed Pre-certification of hospital admissions,outpatient surgery,DME and other services. Provided education of internal as well as external customers of the manage care process. If clinical did not meet Milliman criteria a referral was sent to the Medical Director for a review and determination.

Facilitated patient continuity of care with the health care team. Used criteria such as ( InterQual/ TMF) resources to performed utilization review of admission and communicated with third party payers. Prepared for discharged planning at the start of admission and worked as patient/family advocated /liaison for any specific questions or concerns as it related to care planning , insurance authorization , available in-network options for providers such as Home Healthcare/DME providers. Collaborated with the social worker team to insure the patient had access to needed resources available prior to discharge.