• Supervise RNs conducting prior authorization (Medicaid, Medicare, Marketplace) review in transplant, home health, DMEs, etc., secondary denial letter quality review, Medicare inpatient transition of care (TOC) need prior auth review, and Medicare inpatient concurrent and appeal/ claim review (MCG).•Oversight of daily administrative functions including staffing, productivity, and work quality (quality review). • Creates program specific standardized protocols and policy and procedure and revision on annual basis.• Conduct utilization review using MCG, American College of Radiology (ACR), InterQual, Medicare (NCD/LCD) and Medicaid criteria. Medicare inpatient TOC review and appeal/ claim review. • Conduct Webex training for team RNs as needed and host monthly meeting among program reviewers and medical staff.

• Conduct new hire and in-service staff training on Medicare criteria and CMS regulation.• Create workflow processes and Quick Reference Guides and quality initiative. • Maintain training material on the SharePoint site for staff reference. • Acted as subject matter expert for new and existing staff in Medicare regulation and compliance.

• Managed pediatric patients with complex medical conditions, ie. NICU graduate post discharge, seizure disorders, TBI, asthma, diabetes, Sickle Cell Disease, Cystic Fibrosis, Congenital Heart Disease, etc. • Participated in multi disciplinary meetings with health plan MDs, pharmacy, social workers, and fellow case managers. • Care coordination between member’s providers, pharmacy, DME company, Home Health agency, transportation providers, Local Health Department (CSHCS), and DHHS. • Case Managed and referred members with qualifying diagnosis for Children’s Special Health Care Services (CSHCS). • Bridged community resources for member family on the services that are not covered by their insurance benefit. • Coordinated and monitored Molina members’ progress and service requests from their provider to ensure efficient and cost effective care being carried out.