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The sample below is for a Retrospective Review Manager Resume. This resume was written by a ResumeMyCareer professional resume writer, and demonstrates how a resume for a Retrospective Review Manager Candidate should be properly created. Our Certified Professional Resume Writers can assist you in creating a professional document for the job or industry of your choice.

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HEALTHCARE MANAGEMENT

Enthusiastic, self-motivated Healthcare Management boasting extensive training and education, eager to contribute superior patient service, database support, and quantitative and qualitative analyses in a clinical or hospital settings, supporting the goals of a progressive healthcare industry employer. A self-directed professional with superior problem solving, communications, and staff management experience. Consistently meets/exceeds expectations, combining cost containment with quality improvement and customer service initiatives.

CORE STRENGTHS

 Business Management
 Human Resources
 Workforce Coordination
 Customer Service/Support
 Retrospective Review
 Customer Relations/Retention
 Communications
 Staff Leadership/Development

PROFESSIONAL EXPERIENCE
AvMed Health Plans, Gainesville, FL 1998 to Present
2005 to Present: Retrospective Review Manager
 Directed all facets of Medicare Risk Adjustment initiatives with departmental recovery of $73M in Risk Adjustment revenue since tenure.
 Oversee clinical component that includes identification of clinical suspects, managing internal/external review processes, and reconciliation—successfully gaining $35M over past four conducted reviews.
 Establish Assessment /Transition of Care processes that assess clinical status of new enrollee and provide proactive referrals to Case, Disease, and Pharmacy Management Programs.
 Effectively track Member reported conditions for risk adjustment review purposes and validated or refuted by treating physician.
 Oversee Provider Claim Appeal processes, detailed clinical review of documentation of Member’s medical records in comparison with billed charges, and provide interaction with Medical Director to formulate final case dispositions.
 Perform Clinical Claim Review and Processing assessment that configures diagnosis (ICD-9) and CPT and HCPCS procedure codes for limitations and medical necessity, consistently suppressing more than $1M each quarter.
 Track department activities in customized databases, and queried to monitor and track distinct patterns, trends, and cost savings.
 Close collaboration with internal key areas; Claims, Configuration, Contracting, Medical Operations, Audit Services and Investigations, and Enrollment and Premium Services.
 Manage 22 direct reports and supervise 4 key functions for AvMed Health Plans.
2003 to 2005: Preauthorization Manager
 Provided overall management for up to 20 employees, and oversaw telephone and faxed in prior authorization requests—reviewed for clinical integrity and either approved or denied based on InterQual criteria.
 Close collaboration with medical Director, assisted with clinical determinations and developed denial services letters.
 Strategically designed department workflow procedures, efficient production, all disciplinary actions required and interviewee and hired all new personnel with oversight on payroll and scheduling activities.
2002 to 2003: Training & Quality Clinical Coordinator
 Coordinated quarterly staff audits and designed corrective action plans for issues.
 Developed department training programs and procedures for medical and technical information, and developed and implemented training activities for Preauthorization Department staff.
1998 to 2000: Preauthorization Coordinator
 Oversaw administration of prior authorization requests, utilized InterQual criteria, interacted with Medical Director to efficiently review all information for accuracy, and determined admission legitimacy, treatment, length of stay in health care facility to verify compliance with insurance company reimbursement policies.

Early Career:
Shands at the University of Florida Teaching Hospital, Gainesville, FL – 1990 to 1998
Operating Room Charge Nurse I – 1993 to 1998
75 Surgery Charge Nurse I – 1990 to 1993

EDUCATION
B.S., Healthcare Administration – Santa Fe College, Gainesville, FL (expected graduation xxxx)
A.S., Nursing – Santa Fe College, Gainesville, FL – 1990
Licensed RN – state of Florida

TRAINING / AFFILIATIONS / AWARDS
CMS Risk Adjustment Training program – Medicare in Baltimore, MD
Diversity Training program – AvMed Health Plans
Managerial Training program – AvMed Health Plans
Software training programs:
MS Office (Word, Excel, Access) │ AMISYS │Macess │Plan Data Management │Casetrakker │InterQual │Millman

Affiliations:
Committee Leader for 4 years for companywide United Way Campaign
Committee Leader for last year for companywide March of Dimes Campaign

Awards:
Recipient of “You Make a Difference” award – 2006

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