I have extensive experience in utilization review, having worked in this field for over five years. My role involved analyzing medical necessity, reviewing treatment plans, and ensuring compliance with insurance guidelines. I am proficient in using various review software and have successfully managed to reduce denials and improve patient care through meticulous review processes.

Handling conflicts requires a balanced approach. I first ensure I fully understand the patient's medical needs and the insurance guidelines. Then, I work collaboratively with the healthcare team to find a solution that meets the patient's needs while adhering to the guidelines. If necessary, I escalate the issue to seek additional support or negotiate with the insurance company.

I regularly attend webinars, participate in professional networks, and subscribe to industry publications to stay informed about changes in healthcare regulations and insurance policies. Additionally, I engage with continuing education courses specific to utilization review to ensure my knowledge remains current and comprehensive.

In a complex case involving a patient with multiple chronic conditions, the initial treatment plan was denied by the insurance company. I conducted a thorough review, gathered additional medical documentation, and presented a revised plan that aligned with the insurance criteria. Through persistent communication and negotiation, I secured approval for the treatment, significantly improving the patient's health outcomes.

I prioritize tasks by assessing urgency and impact. I create a daily checklist and update it regularly based on new tasks and changes in patient status. I also delegate when appropriate and collaborate with the team to ensure critical tasks are addressed promptly. This approach helps maintain efficiency and manage stress effectively in high-pressure situations.