Terry Burley
Dacula,GA
Summary
Experienced and highly skilled healthcare professional with a proven track record of getting things done. Extensive experience in supervising and managing teams. Expert in the areas of utilization review, case management, clinical recovery auditing, and quality management. Effective at building and maintaining relationships with customers and vendors. Consistently recognized for outstanding performance.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Manager of Medical Review
CGS Administrators
04.2022 - Current
- Encouraged employee engagement, collaboration, and continuous learning opportunities.
- Defined clear targets and objectives and communicated to other team members.
- Achieved departmental goals by developing and executing strategic plans and performance metrics.
- Maximized performance by monitoring daily activities and mentoring team members.
- Recruited, interviewed and hired employees and implemented mentoring program to promote positive feedback and engagement.
- Identified fraudulent billing patterns through claims data and claim system editing and forwarded to leadership team for discussions and further followup actions
- Provided day to day oversight of the claims review team and team leads
- Drove operational efficiency through data-driven decision-making processes, leveraging analytics tools for informed strategy development.
- Demonstrated strong organizational and time management skills while managing multiple projects.
Senior Nurse Medical Management/ Team Lead
Amerigroup /Anthem
05.2014 - 09.2021
- Provided day-to day- oversight of the Clinical Review team .
- Monitored team and individual quality and quantity metrics.
- Delegated tasks appropriately among team members according to their skill sets ensuring efficient workflow.
- Utilized InterQual and Medical Policies to evaluate medical necessity and applied knowledge of applicable Medicaid rules and regulations to the authorization process.
- Monitored work ques and ensured an appropriate allocation of resources within the team are distributed to meet operational and quality goals .
- Exercised leadership capabilities by successfully motivating and inspiring others.
- Monitored team performance and provided constructive feedback to increase productivity and maintain quality standards.
- Held weekly team meetings to inform team members on company news and updates.
- Audited clinical and nonclinical team members to confirm compliance with set procedures and quality requirements.
Clinical Recovery Auditor
PRGX
06.2012 - 11.2013
- Reviewed, assessed,and evaluated clinical information post payment to determine the appropriateness of the billed level of care .
- Performed second level provider reconsideration reviews and prepared cases for final decision by Medical Director.
- Consulted with Medical Director to review requests for providers requesting peer to peer review for cases with billed charges that did not meet inpatient level of care.
Managed Care Quality Director
Department of Community Health
06.2011 - 06.2012
- Managed a clinical team in collaboration with data analysts for reporting of quality performance metrics to CMS .
- Managed contracted vendors billing for projects and ensured specified work plans and timelines were provided and carried out in accordance with plan.
- Presented Medicaid analysis report to the State of Georgia Medicaid Conference.
- Assisted in recruiting, hiring and training of team members.
- Established a culture of continuous improvement by fostering open communication channels and empowering employees to voice their ideas.
- Low Birth Weight Committee member tasked with collaborating with medical physicians, medical facilities, and other health care professionals to put some initiatives in place to help reduce deaths of infants with low birth weight .
- Work collaboratively with Data Analyst and Vendor on reporting HEDIS measures and collecting data to ensure that providers were providing the appropriate health related screenings to children per the EPSDT guidelines for Georgia .
Utilization Review Nurse / Lead Nurse
Care Improvement Plus
01.2010 - 04.2011
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Supervised and maintained all utilization review documentation through [Software].
- Performed admission reviews based for medical necessity .
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
- Served as subject matter resource, providing information related to denial situations.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
- Performed prior authorization review of services requiring notification.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Inpatient Care Advocate
United Health Group
07.2006 - 12.2009
- Organized supporting documentation for individuals under evaluation and coordinated paperwork transfers to correct staff members.
- Participated in professional development initiatives for consistent improvement and up-to-date knowledge of emerging trends and best practices.
Utilization Review Nurse
Intracorp
05.2003 - 07.2006
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
Hospital Staff Nurse/Charge Nurse
Grady Memorial Hospital/Agency Travel Nursing
- .Streamlined workflow processes to increase efficiency in a high-volume clinical setting.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Assisted physicians with diagnostic procedures, ensuring accurate results for optimal treatment planning.
Education
Master's in Business Administration - Health Care Management
University of Phoenix
Bachelor of Science - Nursing
Valdosta State University
Valdosta, GASkills
- Experience supervising multiple teams of healthcare professionals
- Experienced at improving team performance
- Experience working with and cultivating vendor relationships
- Project Management experience
- Presenting experience
- Relationship Building
- Decision-Making
- Employee Motivation
- Workload Management
- Team Collaboration
Certification
Certified Case Manager, CCM
Accomplishments
- Recognized for consistent cost savings and productivity.
- Recognized as SME (subject matter expert)
- Received several certificates and monetary awards for consistently meeting or exceeding productivity which lead to achievement of team and company related goals.
- Values in Action Award Recipient
Timeline
Manager of Medical Review
CGS Administrators
04.2022 - Current
Senior Nurse Medical Management/ Team Lead
Amerigroup /Anthem
05.2014 - 09.2021
Clinical Recovery Auditor
PRGX
06.2012 - 11.2013
Managed Care Quality Director
Department of Community Health
06.2011 - 06.2012
Utilization Review Nurse / Lead Nurse
Care Improvement Plus
01.2010 - 04.2011
Inpatient Care Advocate
United Health Group
07.2006 - 12.2009
Utilization Review Nurse
Intracorp
05.2003 - 07.2006
Hospital Staff Nurse/Charge Nurse
Grady Memorial Hospital/Agency Travel Nursing
Master's in Business Administration - Health Care Management
University of Phoenix
Bachelor of Science - Nursing
Valdosta State University
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