SUMMARY:

• Clinical Implementation Specialist - Business Change Manager - Clinical Consultant
• Workflow Redesign - Education and Training Development and Delivery - Data Analysis - Quality Improvement
• Conflict Management - Research - Medical Record Review, Analysis and Remediation - Product Life Cycle Management

PROFESSIONAL EXPERIENCE:

Confidential, Atlanta, GA

Senior Case Manager

• Conduct assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
• Ensure member access to services appropriate to their health needs
• Implement care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
• Coordinate internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary
• Interface with Medical Directors and Physician Advisors on the development of care management treatment plans
• Negotiate rates of reimbursement, as applicable
• Assist in problem solving with providers, claims or service issues
• Assist with development of utilization/care management policies and procedures
• Contribute leadership and work guidance to less experienced personnel

Confidential, Bellevue, WA

Senior ICD-10 Specialist

• Facilitated cross-functional mapping sessions with clients for decisions concerning
• reviews of clinical documentation, policies, procedures, benefit configuration, financeand claims processing.
• Gathered business requirements and facilitated design workshops
• Developed and reviewed mapping approaches with clients, creating a mapping
• strategy for the project, ensuring customer success in their ICD-10 migration needs
• Monitored project progress by creating daily and weekly progress tracking sheets,
• communicating project progress and issues to the team as needed
• Provided leadership and work guidance to less experienced personnel

Confidential,Atlanta, GA

Senior Case Manager

• Delivered case management services for case load of 90-120 members with, complex and chronic care needs in accordance with benefits, ethical, legal, accreditation, and regulatory standards
• Improved members’ health and promoted wellness and autonomy through advocacy and empowerment of members in a supportive and objective manner
• Delivered inpatient and outpatient prospective, concurrent and retrospective review of services to ensure that care criteria were met for payment according to CMS, InterQual, Milliman Guidelines, internal regulations and benefits structures
• Contributed leadership and work guidance to less experienced personnel
• Produced utilization and care management policies and procedures
• Optimized member health care across the care continuum by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans
• Maximized cost savings by negotiating rates of reimbursement, interfacing with Medical Directors and Physician Advisors on the development of care management treatment plans and ensuring member access to services appropriate to their health needs

Confidential, Atlanta, GA

Program Manager

• Increased NCQA/HEDIS post-partum follow up visit rate by 20% by developing and implementing incentive programs, tracking outbound call metrics, educating providers and staff on requirements
• Performed HEDIS onsite reviews
• Produced timely and consistent mailing of Healthy Baby materials to population meeting criteria
• Received numerous service award for innovative ideas and suggestions
• Care management within the scope of licensure for HMO, ASO, POS, PPO and Medicare Advantage members with catastrophic, complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum
• Conducted inpatient and outpatient prospective, concurrent and retrospective review of inpatient stays and outpatient services to ensure that care criteria were met for payment according to CMS, InterQual, Milliman Guidelines, internal regulations and benefit structures such as HMO, ASO, POS and PPO
• Delivered telephonic and on site coordination of care and healthcare education to members with catastrophic, complex and chronic care needs in accordance with benefits, ethical, legal, accreditation, and regulatory standards to improve members’ health and promote wellness and autonomy through advocacy and empowerment of members in a supportive and objective manner using the case management process for case load of 90-120 HMO, ASO, POS and PPO members
• Saved $1,500.00 per member by negotiating rates of reimbursement, bed days, interfacing with Medical Directors on the development of care management treatment plans and ensuring member access to services appropriate to their health needs
• Assist in problem solving with providers, claims or service issues
• Assist with development of utilization/care management policies and procedures
• Contribute leadership and work guidance to less experienced personnel

Confidential

Home Healthcare Provider

• Developed, implemented, coordinated and monitored a plan of care with the family, therapists, physicians and community resources such as Babies Can’t Wait and Early Intervention
• Shift Charge Nurse responsibilities

Confidential

Software System Trainer

• Shift Charge Nurse responsible for staff assignments, attending high risk deliveries for newborn assessment, management and resolution of complex issues
• Responsible for facilitating classroom interactive end user training, assess and monitor skills, knowledge and proficiency of participates with new EHR, basic computer and internet skills
• Served as a Super User mentoring other less experienced staff in EHR use

Confidential

Healthcare Provider

• Shift Charge Nurse responsibilities; assisted in directing personnel to meet goals and objectives of the department and institution. Maintained staff scheduling. Participated in institute committees and staff development initiatives