Regina Streitmatter

• Conducted inpatient utilization reviews to ensure compliance with admission criteria.
• Checked pre-authorization submissions for necessary details before processing.
• Engaged in training sessions about new technologies for utilization review.
• Applied evidence-based guidelines to inform utilization review decisions.
• Conducted pre-certification, concurrent review, and retrospective evaluation for inpatient/outpatient care.
• Analyzed cases using medical criteria and clinical judgment to finalize decisions.
• Directed cases to secondary review due to unmet criteria.

* Independently collaborate effectively with interdisciplinary care team to establish an individualized transition plan for members

* Independently serves as the clinical liaison with hospital, clinical and administrative staff as well as perform reviews for clinical authorizations for inpatient care utilizing evidenced-based criteria within the documentation system

* Perform expedited, standard, concurrent and retrospective telephonic clinical reviews at in network and/or out of network facilities. Document medical necessity and appropriate level of care utilizing nationally recognized clinical guidelines for authorizations.

* Interact and effectively communicates with facility staff, members and families and/or designated representative to assess discharge needs, formulate discharge plan and provide health plan benefit information

*Manages assigned case load in efficient and effective manner utilizing time management skills

*Conducts transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care

*Independently confer with UM medical director and/or market medical directors on regular basis regarding inpatient cases and participates in department huddles

* Refers cases to UM medical director as appropriate for review for cases not meeting medical necessity criteria or for complex case situations.

• Supervised and managed daily activities of clinical team consisting 25 physicians, nurses and support staff. Covered the SE Texas region.
• Created weekly schedules for nurses, taking into account sick days and vacation time.
• Ordered and maintained appropriate stock of medications and supplies.
• Implemented ongoing learning strategies such as tutorials, instructional modules, and supervised hands-on sessions to help nurses and staff improve understanding of medical equipment and care best practices.
• Developed, implemented, revised and evaluated policies and procedures.
• Implement new policies and educate staff on changes.
• Oversaw quality assurance programs to enhance performance and consistently achieve superior care standards.

• Established new policies and updated existing policies to improve standard of care for patients.
• Collaborated with staff, management and external groups to coordinate patient care.
• Prepared and reviewed infection control surveillance reports to identify trends and develop effective actions to control and prevent infections.
• Identified department issues to recommend corrective actions.
• Recruited and developed over 20 quality individuals to develop accountable top quality staff.
• Evaluated work performance of 15 nursing personnel to determine wage increases and implement discipline.
• Developed positive employee relations, incentives and recognition programs to promote teamwork and mutual respect.
• Participated in weekly management team meetings to discuss resident status, census changes and resident complaints or concerns.