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Click here or scroll down to respond to this candidateCandidate's Name
Street Address 38th Street SE
Paris, Texas Street Address
PHONE NUMBER AVAILABLE
EMAIL AVAILABLE
QUALIFICATION SUMMARY
Senior healthcare leader and director with comprehensive experience in operations, claims and denial management, program development, utilization review, case management, strategic planning, cost containment and quality improvement.
Strong clinical expertise combined with problem solving abilities for healthcare finance and delivery challenges.
Created denial avoidance and management model at Harlem Hospital Center. Selected by Health and Hospitals Corporation of New York City to develop the denial management system to reduce denials and increase the number of successful appeal outcomes. This system became the standard for best practice throughout the corporation.
Significant knowledge of both Milliman Care Guideline and InterQual. Criteria providing education for documentation improvement and application when writing an appeal.
EDUCATION
MS, Health Services Management and Urban Policies, 2001.
New School University, New York, NY
REMRIT, Certification in Magnetic Resonance Imaging, 1994,
Ultrasound Diagnostic Center, Elmsford, NY
MS, Communication Disorders, 1991, SUNY College at New Paltz, New Paltz, NY
MD, with Honors, 1982, Chandka Medical College, Larkana, Pakistan
PROFESSIONAL EXPERIENCE
PARIS REGIONAL MEDICAL CENTER, 865 DeShong Dr., Paris, Texas 75460 Paris Regional Medical Center, is a licensed for over 300 bed, general acute-care hospital serving Northeast Texas and Southeast Oklahoma. Our health and wellness services include cardiac rehabilitation, diagnostic imaging, digital mammography, emergency healthcare, heart hospital services, intensive care, laboratory services, men s health, orthopedics, physical rehabilitation, senior transitions inpatient, psychiatric programs, women health services, wound care and pediatrics. Fully accredited by the Joint Commission on Accreditation of Healthcare Organizations and a member of Texas Hospital Association
Director of Case Management, June 2016 to December 16:
Reduction of Medicare Acute LOS.
Reduction of Total Hospital Acute LOS from 4.16 to 3.4.
Reduction in more than 20% Excess Days and avoidable days
Effectively start on board multidisciplinary services daily huddle.
Directly responsible for the continuing education and enhancement knowledge base for Case Management Department.
Direct supervision of Case Mgmt staff and day to day operations within the Department
Start the ED Case Management Program with focus on quality and appropriateness of admission, including close coordination with medical staff toward that end.
Effectively start 24/7 case management consultation services.
Implementation of all current and upcoming CMS regulations.
Serve as advisor for current denials, as well delineation of as system improvements for future revenue preservation.
Regular and situational reporting to CMS regarding case management and quality issues.
OCHSNER BAPTIST MEDICAL CENTER, 2700 Napoleon Avenue, New Orleans, LA 70115 Ochsner Baptist Medical Center is a part of biggest health system in Louisiana. As a 173-bed acute care hospital, Ochsner Baptist Medical Center offers the opportunity to learn and provide patient care at a Magnet facility with three Centers of Excellence. Ochsner Health System is a non-profit, academic, multi-specialty healthcare system. Ochsner continuously meets the ever-changing needs of their patients and community through electronically-linked hospitals and health centers.
Director of Case Management, October 2015 to June 2016:
Reduction of Medicare Acute LOS.
Reduction of Total Hospital Acute LOS from 4.06 to 3.76.
Directly responsible for the continuing education and enhancement knowledge base for Case Management Department.
Start ED Case Management Program with focus on quality and appropriateness of status determination, including close coordination with medical staff toward that end.
Implementation of all current and upcoming CMS regulations.
Serve as advisor for current denials, as well delineation of as system improvements for future revenue preservation.
Responsible for complete day to day operations within the Department.
Regular and situational reporting to CMS regarding case management and quality issues.
ST. JOSEPH REGIONAL MEDICAL CENTER, 2801 Franciscan Drive, Bryan, TX 77802
310 bed Level II Trauma Center providing services to residents of the Brazos Valley. Services include the Brazos Valley's only Level II Trauma Center with a Trauma Flight Team. This designation recognizes that St. Joseph is a regional leader in critical care, and the largest provider of cardiovascular care in the region. St. Joseph offers leading-edge diagnostics, comprehensive treatment options including inpatient and outpatient care along with major clinical specialties such as Bariatric Surgery, Cardiovascular, Neurosciences, OB/Gyn, Oncology, Orthopedics and Rehabilitation Medicine. St. Joseph Regional Health Center is the first Joint Commission certified Primary Stroke Center and the first accredited Chest Pain Center in the Brazos Valley.
System Director of Case Management, March 2014 to October 2015:
Reduction of Medicare Acute LOS from 4.67 to 3.71 during March-September, 2014.
Reduction of Total Hospital Acute LOS from 4.06 to 3.76 during March-September, 2014.
Oversight of Case Management Department for all St. Joseph Health System short term facilities (SJRHC, Bellville, Grimes, Madisonville, and Burleson).
Directly responsible for the continuing education and enhancement knowledge base for Case Management Department.
Expansion of the ED Case Management Program with focus on quality and appropriateness admission determination, including close coordination with medical staff toward that end.
Implementation of all current and upcoming CMS regulations.
Serve as advisor for current denials, as well delineation of as system improvements for future revenue preservation.
Responsible for complete day to day operations within the Department and St. Joseph Health System for Case Management.
Regular and situational reporting to CMS regarding case management and quality issues.
System wide provision for education for general nursing staff and new physicians.
Coordination with system entities for improvement of Case Management initiatives.
WESTCHESTER MEDICAL CENTER, 100 Woods Road, Valhalla, NY 10595
652 bed Level 1 trauma center providing services to residents of the Hudson Valley. Services include: 24 hour emergency response team, STAT Flight team, Adult and Pediatric Trauma and Burn Center, state-of-the-art Cancer Center, Transplant Center for: heart, kidney, liver, corneal and bone marrow transplants, Hybrid OR, Cardiothoracic and Vascular surgery services, advanced imaging center, Neonatal intensive care unit, and OB/GYN services with specialties in high risk pregnancies, perinatal and neonatal care. Also on campus is a101 bed inpatient Behavioral Health Center as well as The Maria Fareri Children s Hospital the only pediatric all-specialty hospital in the area. (136 beds)
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Director of Case Management, August, 2013 to March, 2014:
Directly responsible for the continued education and enhancement of Case Management s expertise in Milliman and InterQual criteria, identifying the case manager as an educator and resource person for medical staff. This training significantly improved clinical documentation and review standards, which resulted in improved admission criteria and decrease in the number of denials
Supervise Case Management staff to ensure quality clinical reviews. Serve as a liaison between staff and physicians as needed.
Extended the ED Case Management program with focus on improving the quality of admissions and reducing one day stay denials. This initiative also benefited the Project Red team reducing the number of inappropriate admissions and re-admissions.
Implemented a process to identify observation patients, monitor the level of care and notify designated departments of status changes. .
Oversee the implementation of the new CMS IPPS 2 midnight rule and provide education and supervision to medical personnel as needed.
Serve as a resource person to attending physicians with specific emphasis on accurate precertification procedures, thereby preventing technical denials.
Closely monitor and assess the reasons for all readmissions. Maintain statistics to formulate strategies to decrease the number of readmissions, including weekly contact with patients once discharged.
Participated in the development and establishment of an Observation Unit.
Confer with Patient Accounts to ensure that billing reflects the patient s appropriate level of care.
Review and analyze statistical data reported by the denial management system. Monitor trends, appeal determinations and number of denials. Formulate strategies to reduce the number of denials including the identification of physician responsibility, ongoing education and assist with the written appeal.
Encourage active participation by the physician in the appeal process with the goal of reducing denials to ensure timely reimbursement in the revenue cycle.
The hospital has reported a reduction in medical necessity denials from 6% of total admissions to 4.5%.
NYC HEALTH & HOSPITALS CORPORATION, New York, NY
11 teaching hospitals, clinics and outpatient facilities throughout New York
HARLEM HOSPITAL CENTER, New York, NY
286 bed acute care teaching facility and a designated Level 1 Trauma Center, with a full spectrum of specialty services, including a burn unit, an adult intensive care unit, a neonatal intensive care unit, a pediatric intensive care unit, and a cardiac care unit. Harlem Hospital Center has received national recognition as a Bariatric Center of Excellence
Associate Director/Case Management/Utilization Management Department, 2005 August 2013
Among the eleven HHC hospitals, Harlem Hospital is recognized as having one of the lowest denial rates as well as a 40% approval rate in appeal outcomes.
In collaboration with medical staff and other departments reduced LOS from 6.9 to 5.4.days.
Restructured the Physician Advisor agreement to maximize accountability and meet TJC and CMS compliance standards.
Assisted physicians with the appeal process through distribution of Milliman and InterQual Care Guidelines, physician education and 1:1 discussion.
Enhanced case manager expertise in Milliman and InterQual criteria identifying them as educators and resource people to assist medical staff. This training significantly improved clinical documentation and review standards, resulting in improved admission criteria and decreased denials.
Designated as a master trainer for the AllScripts Care Management Solution Review System and for the Milliman Care Web QI.
Served as the IPRO and Managed Care liaison.
Established an ED Case Management program to reduce the one day denials, assist the Project Red team thus avoiding unnecessary denials and admission.
Devised a denial management system to ensure timely appeal filing.
Established an ED holding area for extended assessment of SNF patients, decreasing the number of unnecessary admissions.
METROPOLITAN HOSPITAL CENTER, New York, NY
356 bed acute care teaching facility and a designated Level II Trauma Center, with a full spectrum of specialty services.
Senior Management Consultant, Case Management/Utilization Review Department, 2004 to 2005
Provided expert consultant services for executives, department heads, and other departmental personnel. Additionally, provided consultant services for inter-corporate facilities, city wide committees and business organizations.
Establishment and implementation of programs for the evaluation, improvement and regularization of normal business operations.
Prepared administration and departmental organization reports related to normal business operations.
Conducted and supervised the special studies of assigned complex and important management problems.
Participated in the establishment and maintenance of effective cooperation and liaison with executive personnel.
Advocated for placement of clinical reviewer in the ER setting as the first line of defense against inappropriate admissions.
Established a track and trend system for denials.
Provided education to clinical reviewers in order to improve the quality of work to improve outcomes.
Helped in to restructure the department with proper utilization of staff the existing staff.
ORANGE RADIOLOGY, Monroe, NY
A leading, private diagnostic imaging group in Orange County, with more than 15 radiologists covering 5 sites accommodating different modalities.
Marketing Manager, 2003 to 2004
Hired to assist marketing director and physicians to meet marketing needs and requests
Maintained business relationships with referring physicians through personal visits, telephone contact, and mail, with emphasis on the superior film quality and experienced radiologists.
Created literature, training programs and access to a web server for referring physicians.
Coordinated with billing department to keep insurance information updated for referring physicians.
MEDSCAN DIAGNOSTIC, Saddle Brook, NJ
Newly established diagnostic imaging company including all modalities.
Project Director, 2001 to 2003
Maintained compliance with applicable federal, state and local regulations of the healthcare department and licensing of the facility.
Oversight of quality control and quality assurance
Updated policy and procedure manual.
Acted as advisor to trustees.
Ensured insurance accreditation by working with billing personnel
Coordinated with referring physicians to address their concerns on reports.
Established a new facility and obtained certification by state regulatory agencies.
Facilitated company approval by ACR
Acted as administrative liaison to contracted groups and solo practices for overall performance including throughput, customer (patient and MD) satisfaction, documentation and quality.
Participated in commercial contract negotiations process establishing standards for timely notification and reporting, changes to payer manual and grievance procedure
Accommodated the needs of customers (MDs and patients) by extending hours of operation
ARDEN HILL HOSPITAL, Goshen, NY
90+ bed acute care hospital
Inpatient Care Manager, 1999 to June 2001
Interfaced with physicians, nurses and other health care team members to meet patient needs and provide quality care while reducing length of stay and costs. Maintained compliance with regulatory requirements
Case Management functions include the use of: pre-established criteria, information from healthcare team, nursing judgment, knowledge of regulatory agency and fiscal intermediary review requirements.
Extensive knowledge related to IPRO, regulatory agencies, managed care regulations and guidelines, Medicare and Medicaid guidelines, continued stay/administrative denials and discharge planning regulations.
Provided Admission / Continued Stay / and Retrospective reviews to third party insurance companies.
Appealed denied cases utilizing InterQual and Milliman Care Guideline criteria.
CLINICAL EXPERIENCE
After graduating from medical school I passed the competition exam; out of more than 3000 candidates, only 172 qualified. I was appointed as a Registrar of the ENT Department of Chandka Medical College Hospital. My major responsibilities as Registrar were:
1-Managing the ENT Department
2-Teaching 3rd, 4th and 5th year medical students
3-Teaching 3rd, 4th and 5th year nursing students
4-Operating ENT OPD treating a minimum of 50 patients per day.
5-Scheduling all surgical procedures
6-Demonstrating surgical techniques for the education of medical students and residents
7-Maintaining health department standards.
8-Organizing the final year ENT annual exam
9-Working as a member of final year ENT viva voce team
10-Maintaining outpatient and inpatient supplies.
11-Assisting the medical director ordering equipment and supplies for the department.
12-Conducting daily department activities. |
