I have extensive experience with various utilization management software platforms, including InterQual and Milliman Care Guidelines. I have utilized these tools to assess the medical necessity of services, develop care plans, and monitor patient outcomes. My proficiency in these systems has enabled me to effectively collaborate with healthcare providers and ensure that patient care is both appropriate and cost-effective.

In high-pressure situations, I prioritize tasks based on urgency and impact. I start by addressing immediate patient needs and critical issues that could affect outcomes. I then organize remaining tasks using a structured approach, such as the Eisenhower Matrix, to ensure that important and urgent tasks are completed first. This method helps me maintain focus and efficiency while managing multiple responsibilities.

To ensure compliance with regulatory standards, I regularly review and update policies and procedures to align with current guidelines. I also conduct regular audits and training sessions to educate staff on the latest regulations. By fostering a culture of continuous improvement and vigilance, I ensure that our practices remain compliant and that any deviations are promptly addressed.

Handling conflicts between patient care needs and cost constraints requires a balanced approach. I prioritize patient safety and quality of care while seeking cost-effective solutions. This involves engaging in open communication with healthcare providers, exploring alternative treatments, and leveraging evidence-based practices to ensure that care is both appropriate and financially sustainable.

One successful project I led involved reducing hospital readmissions by 20% within six months. I implemented a comprehensive care management program that included regular follow-ups, medication management, and patient education. By closely monitoring patient outcomes and adjusting care plans as needed, we achieved significant improvements in patient health and reduced healthcare costs.