MARCY HAMILTON
Maricopa,AZ
Summary
Experienced healthcare and pharmaceutical professional with prior skills for reimbursement management and sales representation. People-oriented leader with strong interpersonal skills, adept at engaging others in decision-making processes. Compassionate and detail-oriented, known for high energy and the ability to de-escalate tense situations effectively. Skilled in teaching and training using diverse techniques tailored to individual learning styles. Works well independently, excels in prioritizing projects and multitasking while maintaining confidentiality. Additional willingness to travel and live near a major airport. Overall, trusted, loyal and consistently timely in all endeavors.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Utilization Manager, Behavioral Health
Blue Cross Blue Shield of Arizona
01.2022 - Current
- Ensured timely follow-up and demonstrated urgency to both accounts and patients.
- Utilize clinical expertise to assess treatment plans, applying evidence-based standards and practice guidelines across levels of care, ensuring appropriateness and effectiveness.
- Manage and review care processes for both pediatric and adult members, coordinating, monitoring, and evaluating options to ensure the provision of appropriate healthcare services and benefits.
- Provide triage and crisis support, gathering clinical information to make coverage determinations/recommendations, and facilitate effective discharge planning.
- Coordinating with healthcare providers and other stakeholders to optimize care/treatment, identifying and facilitating referral opportunities for members at risk of poor outcomes.
- Contribute expertise to promote quality and effectiveness in healthcare services and benefit utilization, conducting concurrent reviews, training new team members, and facilitating substance abuse treatment reviews.
- Implemented strategies aligned with Business Unit and Corporate goals to achieve objectives.
Utilization Manager, Behavioral Health
Aetna
11.2019 - Current
- Maintained accurate expenses within budget and completed all required reports and records in a timely manner. Coordinate healthcare services to optimize benefits for members, monitoring and evaluating options effectively.
- Collaborated closely with external and internal customers to troubleshoot specialty pharmacy-related issues and onboard/train institutional specialty pharmacies.
- Offer crisis support and triage services, applying clinical judgment to render coverage determinations and recommendations.
- Facilitate seamless care transitions by coordinating with providers and integrating services for effective discharge planning.
- Proactively identify at-risk members, facilitate referrals, and enhance healthcare quality through utilization management expertise.
- Analyzed data and developed actionable steps to drive business outcomes.
Senior Analyst Rehabilitation Specialist
CIGNA
09.2017 - 11.2019
- Established and fostered strategic relationships with assigned providers and provider accounts.
- Monitored, documented, and communicated coverage policy changes to internal and external stakeholders.
- Provided education to providers on payer prior authorization requirements, appeals processes, clinical criteria, and coding information.
- Collaborated with medical professionals to enhance internal customer service, managing daily productivity requirements and completing reports within set timelines.
- Prepared comprehensive vocational reports, incorporating medical, psychological, and vocational information to facilitate file determinations.
- Ensured timely responses to internal customers, influencing various file decisions and facilitating next steps in the process.
- Engaged with internal and external stakeholders to support decision-making in the ERG department regarding claim determinations.
- Supervised industry-related projects, presenting trends and industry standards changes at bimonthly meetings, while actively researching the local labor market to assess claimants' potential for alternative job placement.
Vocational Specialist
State of Oklahoma
09.2016 - 09.2017
- Oversaw caseload of consumers with disabilities, ensuring effective delivery of services to facilitate employment, while implementing cost-saving measures to optimize fiscal responsibility.
- Provided counseling and guidance to clients, facilitating goal setting and direction, resulting in successful outcomes.
- Coordinated with regional sales teams to develop payer and reimbursement action plans for key provider accounts.
- Communicated with stakeholders using clear and concise messages, fostering effective collaboration and understanding.
- Developed thorough individual employment plans utilizing medical, psychological, and vocational reports to tailor services to client needs.
- Advocated for employment opportunities for clients with disabilities by engaging with community entities, while presenting program benefits and offering support services as needed in outreach programs.
Staff Therapist
Peak Wellness Center
02.2015 - 09.2016
- Implemented strategies in adult mental health outpatient services to enhance productivity and reduce client wait times, including delegation of services, increased group therapy programming, and revenue optimization.
- Proven ability to thrive independently and within a collaborative cross-functional team.
- Conducted comprehensive utilization reviews of assessments, documentation, and casework for adult service providers, ensuring compliance with agency policies and standards.
- Obtained certification in moral recognition therapy to effectively address substance abuse among adult clients, contributing to increased productivity and targeted treatment outcomes.
- Provided emergency on-call services at hospital and detention facilities, assessing mental health crisis clients and making recommendations to ensure client and community safety.
- Proactively addressed patient-specific issues and provided resolution across the territory.
- Mentored and trained two employees to deliver group therapy services to adult clients, overseeing paperwork review and billing accuracy to maintain quality standards.
Targeted Case Manager, Counselor Intern
Mental Health Center
10.2011 - 02.2015
- Conveyed excellent customer service to clients with severe and persistent mental illness, ensuring timely support and integration into their communities.
- Led and managed 6-8 client appointments daily, meeting productivity requirements and evaluating optimal service plans for community integration.
- Supplied culturally competent services to enhance clients' quality of life by facilitating their integration into communities.
- Consistently ranked in the top 10% for productivity standards throughout employment, demonstrating efficiency and effectiveness in service delivery.
- Worked alongside Billings Drug Court as a Court Evaluator and Case Manager, ensuring accurate diagnosis and offering case management services and referrals to various programs for clients, while maintaining professional communications with government, private, and healthcare entities.
Education
Master of Science (MS) - Rehabilitation and Mental Health Counseling
Montana State University
Billings, MT12.2014
Bachelor of Arts (BA) - Communications
University of Wyoming
Laramie, WY12.2007
Skills
- Microsoft Office Suite
- Adobe InDesign
- Aware
- Electronic Medical Records
- Data Analysis
- Acclaim
- Guiding Care
- Multi Line Phone Systems
- Virtual Communication Systems
- Reimbursement Tools
- Reporting and Compliance
- Resource Allocation
- Adaptability/Resilient
- Attention to Detail
- Reimbursement Expertise
- Collaboration/Teamwork
- Sales Strategy Execution
- Communication Skills
- Problem Solving
- Presentation Skills
- Time Management/Organization
- Counseling
Certification
- National Certified Counselor | The National Board for Certified Counselors | 2020-2025
- Licensed Professional Counselor | State of Arizona | 2019 – 2025
- Licensed Professional Counselor | State of Wyoming | 2016 – 2024
- Certified Rehabilitation Counselor | CRCC | 2014 – 2024
Timeline
Utilization Manager, Behavioral Health
Blue Cross Blue Shield of Arizona
01.2022 - Current
Utilization Manager, Behavioral Health
Aetna
11.2019 - Current
Senior Analyst Rehabilitation Specialist
CIGNA
09.2017 - 11.2019
Vocational Specialist
State of Oklahoma
09.2016 - 09.2017
Staff Therapist
Peak Wellness Center
02.2015 - 09.2016
Targeted Case Manager, Counselor Intern
Mental Health Center
10.2011 - 02.2015
Bachelor of Arts (BA) - Communications
University of Wyoming
Master of Science (MS) - Rehabilitation and Mental Health Counseling
Montana State University
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