Shawn Gross
Lake Orion,MI
Summary
Reliable individual bringing 20 years of experience in healthcare environments. Maintains positive relationships with case managers and providers. Remains polished and calm under extreme stress.
Overview
14
14
years of professional experience
Work History
Utilization Review Coordinator
Behavioral Center Of Michigan
03.2018 - Current
- Obtained 12-15 authorizations from multiple insurance carriers for various levels of care daily.
- Performed prior authorization review of services requiring notification.
- Performed admission reviews based for medical necessity based upon psychiatric specification.
- Supported or performed clinical appeals through devising of appeal letters.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Partnered with physicians, social workers, activity therapists, nutritionists and case managers to develop and implement individualized care plans and documented all patient interactions and interventions in electronic charting systems.
- Audited charts and reviewed clinical documents to verify accuracy.
Utilization Management Coordinator
Havenwyck Hospital
03.2010 - 03.2018
- Performed 20-22 admission reviews based for medical necessity based upon psychiatric specification daily.
- Submitted cases to risk department for criteria failures and helped facilitate resolutions and approvals.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Supported or performed clinical appeals through devising appeal letters.
- Performed prior authorization review of services requiring notification.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Performed ongoing assessments to evaluate mental health needs, working with multidisciplinary team to develop, initiate, manage and modify individualized plans of care.
- Audited charts and reviewed clinical documents to verify accuracy.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
Education
No Degree - Nursing
Wayne County Community College District
Detroit, MI06.2026
Skills
- Interpersonal and written communication
- Physician consultations
- Documentation and reporting
- Discharge planning coordination
- Case Management
- Patient and family advocacy
- EMR / EHR
Timeline
Utilization Review Coordinator
Behavioral Center Of Michigan
03.2018 - Current
Utilization Management Coordinator
Havenwyck Hospital
03.2010 - 03.2018
No Degree - Nursing
Wayne County Community College District
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