Responsible for coordinating all healthcare needs for a national dedicated account. Responsibilities included but not limited to managing activities that involve utilization management for Medical and Behavioral Health needs, case management, disease management and precertification. Utilized Milliman and Medical Policy criteria to determine medical appropriateness as well as ICD 9 codes. Assessed and assisted members in determining the most appropriate and current healthcare needs. Collaborate with hospitals regarding approvals/denials and made appropriate health care referrals to internal and outside vendor on the members behalf. Assisted member coordination in a safe and cost effective manner. Refer cases to Medical Director as appropriate

Staff monitoring of 14 employees for performance utilizing the case mgmt model for clinical and non-clinical staff for quality assurance and adherence to Medicare standards. Provided guidance for staff coordinating care for members with Medical and Behavioral Health needs. Experienced with utilizing Interqual criteria.
-Conducted Medical Chart and Production System Audits.

Held several positions while at Aetna. Designed a DM Program, Supervised clinical and non-clinical center in a DM call center. Also was a case manager whereby I coordinated care by reviewing utilization review precert, d/c planning as well as coordinate case mgmt needs and provided disease mgmt education.