R. Riley Smith
Phoenix,AZ
Summary
A Risk Management Social Worker with 13+ years of experience in behavioral health, case management, utilization management, and performance improvement. My experience also encompasses grievances and appeals from both payors and patients, alike.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Risk and Performance Improvement Specialist
Teri's Health Services
Phoenix, AZ
12.2022 - Current
- Conducted internal audits of the clinical records of clients in the THS system.
- Completed audits for multiple disciples, including nursing staff (RN, MA, BHT), Medical Staff (Primary Care, Psychiatry, and Pharmacy), and Therapy (Counseling, Case Management, Group Therapy)progress notes, treatment plans, assessments, and discharge.
- These audits are based not only on THS's policies and procedures but also meet the standards of ADHS, CMS, AHCCCS, and The Joint Commission. Provided ECW education, training, and ongoing technical (EHR) support to members of the medical staff, including MAs, Nurses (RNs and LPNs), and Providers (NPs, PAs, MDs, and DOs).
- Developed "compliance tracers" that had the ability to track, trend, and analyze trends of deficiencies.
- Promoted and educate best practices surrounding telehealth, including writing protocols.
- Responsible for monitoring, tracking, coordinating and reviewing accreditation requirements and reports for Carf, PCMH, HRSA, etc
Corporate Appeals and Grievance Coordinator
NeuroPsychiatric Hospitals
Phoenix, AZ
12.2021 - 11.2022
- Responsible for investigating and processing the most complex grievances and appeals requests from members and providers related to behavioral health services
- Served as a technical resource to team and assigned to work on projects in support of medical policy and/or managed care initiatives
- Investigated and reviewed member and provider grievances and appeals
- Performed patient chart reviews for quality measures and reporting standards
- Responded to Quality of Care (QOC) concerns from payors.
- Served as an internal resource for lower level behavioral health appeal coordinators and staff
- Reviewed prospective, inpatient, or retrospective medical records of denied services for medical necessity
- Extrapolated and summarized medical information for medical director, consultants and other external review
- Prepared recommendations to either uphold or deny appeals and forwards to the medical director for approval
- Ensured that appeals and grievances are resolved timely to meet regulatory timeframes
- Documented and logged information on tracking systems and mainframe systems
- Generated appropriate written correspondence to providers, members, and regulatory entities
- Participated in projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.
Care Coordinator / Social Worker
Connections Health Solutions
Phoenix, AZ
04.2021 - 12.2021
- I conducted thorough, accurate, clinically sound Psychosocial assessments, identify diagnosis, and LOCUS scores
- Educated and informed patients of the parameters of consents for treatment, modeled healthy communication, and conducted self audits of charts for compliance purposes
- Gathered collateral information from the patient, their clinic, other providers, etc
- Provided a thorough assessment of patient's immediate needs are for treatment and discharge.
- Collaborated with the Treatment team to develop and implement an individualized person-centered treatment plan
Milieu Manager
United Health Services, Valley Hospital
Phoenix, AZ
03.2021 - 06.2021
- Ensured that all therapeutic activities, therapeutic groups, daily schedules are being followed, and implemented while directing direct care staff in guiding patients towards attending their treatment goals.
- Provided trauma informed care, responding to codes, demonstrating appropriate therapeutic interventions, de-escalation techniques to patients with a variety of psychiatric diagnoses and mental health needs.
- Supported staff and provided education on ways of minimizing behavioral outbursts through use of preventative strategies such as building positive relationships, creating a therapeutic environment, being the primary support to patients when additional behavioral support is needed such removal of patient from any type of setting to address any type of therapeutic or behavioral need (e.g., use of coping skills, emotional regulation, crisis intervention , etc.).
- Collaborated with the Unit Nurse Manager to create, maintain a safe, supportive and structured environment for all patients by providing training and education for all unit staff.
Risk Management and Performance Coordinator
Kinetic Health Solutions
Phoenix, AZ
11.2017 - 03.2021
- Maintained a caseload and monitored day-to-day compliance with appeal decision time frames
- Reviewed clinical and medical records for completeness and determined administrative or clinical appeal
- Assigned reviews to physician advisers and medical directors for those requiring medical necessity reviews
- Prepared and presented information on appeals to panels second-level multi-disciplinary committee
- Participated in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provided new employee training, monitored QI (Quality Improvement) activities of the appeals department, and assisted in the development of depart flows and implementations
- Coordinated and distributes first, second and third-level appeal request assignments
- Consulted with managers on problem cases and interfaces with case managers, clinical supervisors, account managers, and other personnel in resolving denial and appeal questions
- Respond to member, provider, and client telephone inquiries regarding the status, process, and outcome of appeals
- Organized volume of work and work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed
Quality Analyst
McKesson Health Industry
Scottsdale, AZ
03.2018 - 07.2019
- Assisted in the design of monitoring format and establishing quality standards
- Performed quality assurance monitors and complete checklist
- Collaborated through calibration sessions with Leadership, Training and Knowledge Management to ensure consistent evaluation
- Performed side by sides and call listening sessions
- Provided feedback to Advocates, Leadership and Trainers
- Analyzed data management system information for training opportunities or gaps
- Build a practical plan to address business needs
- Evaluated performance across all types of the omni channel contacts with customers.
Director of Social Services
Haven Behavioral Health
Phoenix, AZ
10.2013 - 11.2017
- Collaborated with social services staff, interdisciplinary team, and administration to promote and protect patient rights, dignity, independence and psychological well-being
- Maintained good working relationships with center employees, meeting with administration and nursing staff to collaborate and plan
- Assured a comprehensive Psychosocial Assessment is completed for each patient that identifies social, emotional, psychological needs and strengths
- Educated patients and families regarding their rights and responsibilities, health care decision making/ advance directives, effective problem solving, and available community resources
- Provided therapeutic interventions to assist patients to cope with their transition and adjustment to a long-term care facility and to address behavior or mood problems
Utilization Review Coordinator
Choices Network of Arizona
Tempe, AZ
01.2007 - 06.2013
- Reviewed patient admission data and clinical documentation to ensure compliance with county and state regulations relating to medical necessity and case documentation;
- Interviewed clients and significant others and consulted with the existing out-patient team;
- Consulted with medical and treatment staff regarding patient diagnosis, medical justification, length of treatment, and case documentation;
- Assessed records for the appropriate level of care and treatment, aftercare, and discharge planning for patients;
- Represented the Choice's Network in disagreements as to care plans with medical staff at hospitals;
- Advocated for required patient treatment with medical providers; provided training and information about utilization requirements to clinical, supervisory, and management staff;
- Participated with departmental staff in utilization and quality improvement meetings and projects;
- Prepared memorandum, letters, correspondence, and comprehensive daily patient status summaries; and participated in state and federal audits of programs to ensure agency compliance with utilization review regulations.
Mental Health Program Specialist
State of Arizona
Phoenix, AZ
03.2009 - 04.2010
- Taught transitional living skills (personal hygiene, home maintenance, utilization of public transportation, etc.) both implements the Planning Document objectives & programs
- Motivated member groups & coordinates educational & recreational activities for members
- Provided direct personal care & assistance w/daily living skills as needed
- Functioned as a Lead staff and acts in the absence of a supervisor in coordinating and directing the activities of assigned staff, scheduling and prioritizing work activities and providing technical advice and assistance
- Discussed the concerns expressed by members and family members and listens and offers suggestions in accordance with program goals and objectives
- Monitored & assesses member behaviors & reports potential problems for members residing in the facility or in the family's home
- Followed & ensured staff compliance with policy regarding safety procedures
- Attended Planning/Treatment Plan team meetings as an active member for clients in the facility and as needed, for members residing in a family setting or other residential setting
Crisis Intervention ACT Case Manager
New Hope Recovery Center
Boston, MA
11.2005 - 01.2009
- Assists and participates in an interdisciplinary team
- Provided case management and discharge planning services during the individual's stay at the CRU (assessments, referrals, linkages, advocacy, transportation, developing treatment plans, documentation, and monitoring)
- Provided individual-based components of Dialectical Behavioral Therapy-informed via weekly coaching and participated in group facilitation
- Provided emergency and crisis intervention to high-risk clients in our mental health track for treatment- related, treatment-interfering, and treatment-destroying behaviors, including suicidal crises
- Provided as-needed coaching and crisis intervention to clients in need or provided coordination to obtain support from community providers
- Reviewed clinical assessments, formulated treatment plans, and recorded patients' progress in EHR (SOAP note format)
- Evaluated clients for chemical dependency issues; assessed changes in the client's condition/ treatment needs
- Identify service resources; maintain active communication with service providers for care coordination and advocacy.
Education
Master's degree - Social Work
Arizona State University
Watts College, Phoenix, AZ05.2023
Bachelor of Science - Social Work
Arizona State University
Watts College, Phoenix, AZ08.2021
Associate of Arts - Business
Phoenix College
Phoenix, AZ08.2020
Bachelor of Arts - Public Health
Atlantic Union College
Lancaster, MA05.2009
Bachelor of Arts - Psychology
Atlantic Union College
Lancaster, MA05.2009
Skills
- Case management
- Mental health counseling
- Clinical Research
- Microsoft Office
- Hospital experience
- Psychotherapy
- Diversity and inclusion
- Utilization management
- CBT, DBT, MI
- Statistics / Data collection
- Public health
- EMR systems: NextGen, ClaimTrak, Best Notes, Sales Force, Starpoint, ECW
- Project management
- Risk Management
- Group Therapy, Addiction Counseling, and Crisis Intervention
- Managed care and Regulatory reporting
- Strategic planning and Documentation review
Certification
CPR
July 2022 to July 2024
CPI
July 2022 to July 2025
Crisis Prevention Institute
Additional Information
- Willing to relocate: Anywhere, Authorized to work in the US for any employer
Affiliations
- National Association of Social Workers
- Arizona State University Alumni
- Tau Sigma
Timeline
Risk and Performance Improvement Specialist
Teri's Health Services
12.2022 - Current
Corporate Appeals and Grievance Coordinator
NeuroPsychiatric Hospitals
12.2021 - 11.2022
Care Coordinator / Social Worker
Connections Health Solutions
04.2021 - 12.2021
Milieu Manager
United Health Services, Valley Hospital
03.2021 - 06.2021
Quality Analyst
McKesson Health Industry
03.2018 - 07.2019
Risk Management and Performance Coordinator
Kinetic Health Solutions
11.2017 - 03.2021
Director of Social Services
Haven Behavioral Health
10.2013 - 11.2017
Mental Health Program Specialist
State of Arizona
03.2009 - 04.2010
Utilization Review Coordinator
Choices Network of Arizona
01.2007 - 06.2013
Crisis Intervention ACT Case Manager
New Hope Recovery Center
11.2005 - 01.2009
Master's degree - Social Work
Arizona State University
Bachelor of Science - Social Work
Arizona State University
Associate of Arts - Business
Phoenix College
Bachelor of Arts - Public Health
Atlantic Union College
Bachelor of Arts - Psychology
Atlantic Union College
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