Ms. Lenell Watson, M.S.
Norwood,PA
Summary
Healthcare professional with strong foundation in utilization review, clinical assessments, and regulatory compliance. Proven track record in improving patient care outcomes and optimizing resource use. Known for collaborative approach and adaptability to changing priorities, with key skills in case management and data analysis.
Overview
17
17
years of professional experience
Work History
Utilization Review Specialist
Pinnacle Treatment Center
03.2023 - Current
- Performed admission, continued stay and discharge reviews for substance use treatment based on medical necessity directed by ASAM guidelines.
- Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Collaborated with interdisciplinary teams to optimize patient outcomes and enhance service delivery protocols.
- Analyzed data trends to identify areas for improvement in care management practices, driving strategic initiatives.
- Collaborated with leadership to devise initiatives for improving deadline adherence.
- Streamlined documentation processes, increasing efficiency in information retrieval and enhancing overall workflow productivity.
- Conducted thorough assessments for program utilization compliance with healthcare standards.
- Provided timely feedback to clinical and administrative staff regarding documentation, authorizations, benefit limitations, and treatment alternatives.
- Obtained authorizations from multiple insurance carriers for various levels of care. Experience with IN, KY, NJ and PA medicaid and commercial policies.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals. Scheduled peer to peer reviews for higher level appeals.
- Organized and distributed daily UM tasks during morning Flash meetings, and communicated outstanding tasks amongst department leaders.
- Supervised and maintained all utilization review documentation through KIPU and Salesforce.
Admissions Specialist and UM Coordinator
Kirkbride Center
01.2016 - Current
- Managed referral reviews, created EMR profiles, uploaded demographic data, verified benefits, and secured authorizations.
- Collaborated with interdisciplinary teams to address client needs and improve service delivery within admissions framework.
- Assisted applicants with admissions packet and served as point of contact throughout admissions process.
- Ensured adherence to regulatory requirements by conducting regular audits of review processes and documentation practices.
- Managed a high volume of cases efficiently by prioritizing tasks and maintaining strict deadlines for completion of reviews.
- Assisted with audits to ensure compliance with federal regulations governing Medicare and Medicaid reimbursements, safeguarding against potential penalties or sanctions from government agencies.
- Provided timely feedback to physicians regarding patient progress, facilitating adjustments to treatment plans as needed.
- Maintained strict confidentiality of patient information, adhering to HIPAA regulations and organizational policies regarding privacy and data security.
Utilization Review Specialist
The Renfrew Center
01.2020 - 02.2023
- Full time UM staff for a residential and PHP eating disorder program in Philadelphia.
- Gained experience measuring outcomes based on Renfrew’s Unified Treatment model, verifying available resources to support relapse prevention, and increasing my awareness of insurance plan criteria and limitations.
- Meticulously reviewed the active census for any last covered day discrepancies, audited clinical charts to improve compliance through medical criteria, managed multiple active authorizations for residential and PHP levels of care.
- Arrange peer to peer reviews or initiate single case agreements.
- Assigned task coverage for upcoming reviews. Coordinated interdisciplinary meetings to discuss complex cases, fostering collaborative solutions among providers.
- Maintained clinical documentation through EMR, Avatar and Salesforce.
- Evaluated patient treatment plans to ensure compliance with established guidelines and standards.
- Analyzed data trends to identify opportunities for improved patient outcomes and resource management.
- Developed comprehensive reports summarizing findings from reviews, supporting decision-making for treatment approvals.
IOP/OP Counselor
Addiction Medicine and Health Advocates, Inc
03.2009 - 01.2020
- Provided individual psychotherapy for patients utilizing methadone maintenance for long term opiate treatment management in an outpatient setting.
- Developed treatment plans with patients that aimed to increase hard reduction and symptom management skills.
- Performed precerfication to transfer patients to higher levels of care.
- Case management duties including community referrals for behavior and medical management, legal or job readiness training. actions to prepare for readiness.
- Collaborated with medical professionals to ensure comprehensive care for clients.
- Promoted to spearhead other facility duties such as intake and assessment, discharge planning, benefits verification, tracking program utilization, monitor staff training and credentials, and IOP ground facilitator.
Education
Master of Science - Health Psychology
University of The Sciences in Philadelphia
Philadelphia, PA05-2008
Bachelor of Science - Psychology
University of Pittsburgh
Pittsburgh, PA05-2006
High School Diploma -
Philadelphia High School For Girls
06-2001
Skills
- HIPAA compliance
- Quality improvement
- Healthcare regulations
- Medicare compliance
- Utilization management
- Medical necessity criteria
- Private insurance policies
- Insurance verification
- Documentation and reporting
- EMR experience: Availity, Avatar, AMS, Credible, HCS, Kipu, and Salesforce
- Experience working setting Outpatient, Psychiatric, and Residential care settings
- Adaptability and flexibility
Timeline
Utilization Review Specialist
Pinnacle Treatment Center
03.2023 - Current
Utilization Review Specialist
The Renfrew Center
01.2020 - 02.2023
Admissions Specialist and UM Coordinator
Kirkbride Center
01.2016 - Current
IOP/OP Counselor
Addiction Medicine and Health Advocates, Inc
03.2009 - 01.2020
Master of Science - Health Psychology
University of The Sciences in Philadelphia
Bachelor of Science - Psychology
University of Pittsburgh
High School Diploma -
Philadelphia High School For Girls
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