Christie Hayes
Van Nuys
Summary
Detail-oriented healthcare professional with extensive experience in utilization review and case management, specializing in evaluating medical necessity, ensuring regulatory compliance, and optimizing patient care outcomes. Proven ability to collaborate with interdisciplinary teams, interpret clinical guidelines, and apply evidence-based criteria such as InterQual and MCG to support appropriate level-of-care determinations. Skilled in prior authorizations, concurrent and retrospective reviews, and appeals processes, with a strong commitment to cost-effective, high-quality care. Recognized for strong analytical skills, attention to detail, and effective communication with providers, payers, and patients.
Overview
10
10
years of professional experience
Work History
Utilization Review Specialist
Codemax
Van Nuys
07.2023 - Current
- Conducted concurrent, retrospective, and prospective utilization reviews to determine medical necessity and appropriate level of care using InterQual and/or MCG criteria.
- Reviewed patient records for accuracy, completeness, and clinical appropriateness, ensuring alignment with payer guidelines and regulatory standards.
- Collaborated with physicians, case managers, and interdisciplinary teams to optimize patient outcomes and reduce length of stay.
- Managed prior authorizations and pre-certifications, ensuring timely approvals and minimizing delays in care.
- Identified and escalated cases that did not meet criteria, facilitating peer-to-peer reviews and medical director consultations.
- Prepared and submitted appeals for denied claims, successfully overturning adverse determinations and improving reimbursement.
- Monitored and analyzed utilization trends to identify opportunities for cost containment and process improvement.
- Ensured compliance with CMS, Medicare/Medicaid, HIPAA, and accreditation standards (e.g., Joint Commission, NCQA).
- Documented review outcomes clearly and accurately in electronic health records and utilization management systems.
- Provided education to clinical staff on documentation best practices and medical necessity requirements.
- Maintained productivity and quality benchmarks in a high-volume, deadline-driven environment.
- Participated in audits and quality improvement initiatives to enhance utilization efficiency and regulatory compliance.
SUD Counselor
Tarzana Treatment Centers, Inc
Tarzana
04.2019 - Current
- Taught clients anger management techniques, relaxation skills, impulse control and coping skills.
- Monitored behavior in individual and group sessions and intervened when necessary.
- Provided counseling for relapse prevention, social issues and mental health problems.
- Referred clients to other programs and community agencies to enhance treatment processes.
- Liaised with family members to discuss progress and develop ongoing plans for counseling goals.
- Developed comprehensive treatment plans focused on patient goals and history.
- Assisted clients with identifying feelings and behaviors by asking open-ended questions.
- Performed counseling interventions to address issues through conflict resolution and situational adjustment to depression, anxiety, and physical or substance abuse.
Substance Abuse Counselor
The discovery House
Van Nuys
02.2016 - 11.2018
- Educated patients on detox and withdrawal, medications, addiction, recovery, coping skills and community resources.
- Conducted individual and group therapy sessions for outpatient clients.
- Collaborated with patients to establish post-treatment strategies for sobriety.
- Developed effective treatment plans for patients in substance abuse facility.
- Collaborated with team members to monitor treatment progress and improve individual clients' plans.
Education
Some College (No Degree) - Psychology
Pierce College Ca
Woodland Hills, CASkills
- Medical Necessity Determination
- Concurrent, Retrospective, and Prospective Reviews
- Level of Care Assessment (Acute, Observation, SNF, Rehab)
- Evidence-Based Criteria Application (InterQual, MCG)
- Prior Authorization & Pre-Certification
- Denials Management & Appeals Processing
- Clinical Documentation Review & Validation
- Care Coordination & Discharge Planning
Timeline
Utilization Review Specialist
Codemax
07.2023 - Current
SUD Counselor
Tarzana Treatment Centers, Inc
04.2019 - Current
Substance Abuse Counselor
The discovery House
02.2016 - 11.2018
Some College (No Degree) - Psychology
Pierce College Ca