Overview
Work History
Education
Skills
References
Timeline
Generic

Tonia Brinson

Santa Rosa,CA

Overview

17
17
years of professional experience

Work History

Utilization and Review Specialist

Azure Acres
Sebastopol, CA
12.2017 - Current
  • Compiled monthly reports summarizing key findings from review activities.
  • Conducted interviews with customers regarding their experiences with the company.
  • Utilized InterQual criteria to make determinations of medical necessity based upon member benefits plan design and other relevant information.
  • Communicated findings and recommendations to providers regarding authorization decisions.
  • Reviewed pre-authorization requests from physicians and providers and determined medical necessity based on current standards of practice guidelines.
  • Provided consultation to providers on appropriate utilization management strategies when needed.
  • Conducted medical necessity reviews and concurrent reviews of inpatient, outpatient, and home health services to ensure compliance with applicable standards and regulations.
  • Analyzed data trends related to utilization patterns across multiple provider types utilizing various reporting tools.
  • Assessed the need for continued stay by reviewing clinical documentation in order to determine if the admission or continued stay is medically necessary.
  • Performed additional duties as assigned by supervisor or manager.
  • Responded promptly and accurately to inquiries from physicians and providers regarding authorization decisions made on their patients' cases.

UM Concurrent Reviewer, Counselor and Front Office

Campobello CDRC
Santa Rosa, CA
08.2008 - 12.2016
  • Participated in educational programs related to UR and UM topics presented by external organizations or internal staff members.
  • Responded promptly and accurately to inquiries from physicians and providers regarding authorization decisions made on their patients' cases.
  • Conducted medical necessity reviews and concurrent reviews of inpatient, outpatient, and home health services to ensure compliance with applicable standards and regulations.
  • Reviewed pre-authorization requests from physicians and providers and determined medical necessity based on current standards of practice guidelines.
  • Worked closely with Health Plans representatives in resolving issues related to authorization decisions made by the organization.
  • Researched complex cases involving multiple diagnoses or treatments that require a comprehensive approach towards determining medical necessity.
  • Analyzed data trends related to utilization patterns across multiple provider types utilizing various reporting tools.
  • Monitored changes in industry standards related to UM activities and updated policies accordingly.
  • Conducted comprehensive interviews with potential clients to determine eligibility for services.
  • Provided information and resources to individuals, families, and groups seeking assistance.
  • Offered crisis intervention techniques when needed.
  • Ensured compliance with relevant regulations pertaining to the provision of services.
  • Assisted in determining appropriate referrals for clients to other community agencies or programs.
  • Collaborated with multidisciplinary team members to ensure quality care is provided to all clients.
  • Coordinated the intake process for new clients, including scheduling initial assessments and providing necessary paperwork.
  • Adhered to confidentiality guidelines when handling sensitive information about clients.
  • Created individualized service plans for each client based on their unique needs and goals.
  • Maintained accurate records of client intakes in electronic database system.
  • Communicated effectively with supervisors regarding current caseloads and resource availability.
  • Conducted initial risk assessments to identify any immediate concerns or needs for intervention.
  • Assessed client needs through initial interviews and consultations to determine appropriate services.
  • Maintained accurate and up-to-date records of client interactions and services provided.
  • Facilitated communication between clients, family members, and healthcare providers to ensure seamless service delivery.
  • Coordinated the intake process, ensuring all required documentation was collected and processed.
  • Utilized case management systems to track client cases from intake through to completion.
  • Provided leadership, insight and mentoring to newly hired employees to supply knowledge of various company programs.
  • Guided employees in handling difficult or complex problems.
  • Reviewed employees' work to check adherence to quality standards and proper procedures.
  • Implemented departmental policies and standards in conjunction with management to streamline internal processes.

Education

AOD Certificate - Alcohol And Drug Certificate

Santa Rosa Junior College
Santa Rosa, CA
06-2009

Skills

  • Medical necessity determination
  • Utilization management
  • Data analysis
  • Clinical documentation review
  • Authorization decision-making
  • InterQual criteria application
  • Policy interpretation
  • Employment data tracking
  • Time management abilities
  • Problem-solving
  • Microsoft office
  • Onboarding process
  • Candidate searching
  • Analytical and critical thinking
  • Reliability
  • Interviewing techniques
  • Decision-making
  • Diversity and inclusion
  • Drug testing
  • Task prioritization
  • Eligibility determinations
  • Maintain employment records
  • Performance management
  • Relationship building
  • Employee orientation
  • New hire orientation
  • Employee relations
  • Pre-employment screening
  • Employee hiring
  • Benefits administration
  • Exit interviews
  • Documentation and recordkeeping
  • Change management
  • Contract negotiation
  • Innovation and creativity
  • Task delegation
  • Performance analysis
  • Training and mentoring
  • Crisis intervention
  • Report writing
  • Effective communication
  • Team collaboration
  • Consultation skills
  • Customer relationship management

References

References available upon request.

Timeline

Utilization and Review Specialist

Azure Acres
12.2017 - Current

UM Concurrent Reviewer, Counselor and Front Office

Campobello CDRC
08.2008 - 12.2016

AOD Certificate - Alcohol And Drug Certificate

Santa Rosa Junior College

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Tonia Brinson