Kristi Willson Email & Phone Number

Provided guidance to ensure medical management programs were competitive in the industry, contributed to profitable growth, and were compliant with all legislative requirements.• Responsible for ensuring compliance with states’ managed care and grievance and/or external review laws.• Prepared and submitted state certification applications for the performance of utilization review. Completed state reports, responded to requests for information from state insurance departments and assisted with state insurance department audits.• Assisted with the national reaccreditation program for Utilization Management by URAC.• Collaborated with various departments to analyze, develop, and implement compliance methods for the revised Employee Retirement Income Security Act (ERISA) Claims Rules and the Patient Protection and Affordable Care Act Interim Final Rules for group health plans and insurance issuers relating to Internal Claims and Appeals and External Review Processes.

Des Moines, Ia

Performed telephonic utilization review for inpatient hospital admissions and outpatient procedures for group health members to establish the medical necessity and appropriateness of care in accordance with all medical plan provisions, company policies and procedures, state and federal regulations, and URAC Health UM Standards.• Conducted prospective, concurrent, retrospective, presurgery and pretreatment reviews for medical necessity and appropriateness based on company guidelines and clinical review criteria. Coordinated physician review of cases that fell outside of clinical review criteria standards.• Utilized strong assessment, education and evaluation skills to facilitate members through the continuum of care in a safe and cost-effective manner. • Trained new employee nurses to perform utilization review using utilization review processes and guidelines. Performed quality review for compliance with guidelines and appropriate use of clinical review criteria.

Des Moines, Iowa Area

Managed and coordinated post-operative care of adult and pediatric patients in a critical care unit after open heart surgery or heart transplant surgery. Mentored and oriented new employees to the critical care unit.