Clinical Review Coordinator | Utilization management Ops - Optum - Remote
(2025-04)
- Conduct Pre service review for inpatient Rehab facility (IRF) in compliance with CMS guidelines.
- Analyze and investigate complex issues, identifying root causes and delivering actionable solutions
- Interpret data and apply subject matter expertise to resolve a wide range of operational challenges
- Manage non-standard requests and escalate or collaborate as needed to ensure resolution
- Maintain deep specialization in designated knowledge areas to support consistent, accurate outcomes
- Prioritize workload effectively to meet deadlines and performance targets in a fast-paced environment
- Communicate complex concepts clearly to stakeholders, translating theory into practical applications
- Provide coaching, feedback, and guidance to team members to enhance performance and skill development
- Serve as a subject matter expert and resource for less experienced staff
Clinical Review Coordinator | Home and Community Care - Optum - Remote
(2023-06 - 2025-03)
Conduct utilization review for home health services (SN, PT, OT, ST, MSW, HHA) in compliance with Medicare Chapter 7 guidelines. Maintain clear and professional communication with providers and management.
- Supported utilization review, care coordination, and regulatory compliance for home and community-based programs, serving as a liaison across stakeholders to ensure delivery of medically necessary services
- Managed end-to-end case review processes for home health services, averaging 12–14 cases daily while analyzing high-volume clinical documentation for Medicare compliance
- Collaborated with providers, case managers, and interdisciplinary teams to determine medical appropriateness and optimize patient outcomes
- Delivered provider education on pre-service authorization processes, reducing incomplete submissions and improving workflow efficiency and compliance
- Prepared comprehensive patient summaries and documentation to support coordinated, patient-centered care across interdisciplinary teams
Preservice coordinator | Care Coordinator - Optum - Remote
(2015-10 - 2023-05)
Preservice review (Clinical review for elective surgeries of appendicular skeleton and spine, inpatient care management and post-acute care management. Utilization management for outpatient care (PT, OT, ST)
- Led pre-service utilization reviews for elective surgeries, ensuring medical necessity, insurance coverage, and streamlined authorization processes through collaboration with physicians and case managers
- Analyzed clinical documentation to determine appropriateness of inpatient rehabilitation services (Acute Rehab, LTAC, SNF) for skilled therapies (PT, OT, SLP) using InterQual and MCG criteria
- Conducted quality assurance audits to identify performance gaps, improve compliance with clinical guidelines, and implement targeted training initiatives
- Initiated peer review referrals for cases not meeting established criteria, ensuring adherence to evidence-based standards and organizational policies
- Ensured regulatory compliance and minimized risk by meeting submission timelines and coordinating with contract teams to prevent delays, denials, and service disruptions
Occupational Therapist - Various Employers
(2009-10 - 2020-05)
Experience in Level 1 trauma inpatient and outpatient rehabilitation services at Bellevue Hospital Center; Mercy Medical Center, Skilled Nursing Facilities and home care focusing on acute and subacute rehab for patients with traumatic brain injuries, neurological conditions, and upper extremity injuries.
- Conducted comprehensive patient evaluations and designed custom upper extremity orthotics, collaborating with interdisciplinary teams to improve functional outcomes across all phases of care
- Assessed and implemented assistive technologies and adaptive devices, providing training to patients and caregivers to promote independence and ensure proper integration into care plans
- Partnered with multidisciplinary teams to develop and execute individualized therapy plans, enhancing patient independence through adaptive techniques and rehabilitative interventions
- Mentored new graduate hires through structured onboarding, including shadowing, competency assessments, documentation review, and policy adherence, ensuring successful transition into clinical roles
