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Click here or scroll down to respond to this candidateCandidate's Name -Nearhoof
BSN, RN, CCM, LNC
Street Address
Email; EMAIL AVAILABLE
Cell: PHONE NUMBER AVAILABLE
Confidential Work: PHONE NUMBER AVAILABLE
Summary of Professional Skills:
Professional management clinical with management experience includes a diverse background in specialties including but not limited to medsurg, emergency, long term care, behavioral health, and addictions care; case and disease management in managed care/insurance and workers compensation, and home health/hospice.
Professional insurance career reflects progressive leadership experience for approximately 20 years including workers compensation, utilization and case management; quality improvement as well as extensive experience with NCQA, URAC, and JCAHO. Other skills include medical legal consultation and project management.
Other professional character attributes:
Self-Starter
Succession Planner
Persistent
Change Agent
Objective Situational Leader
Best Practice Vision
Summary of Experience
Progressive Management BCNEPA Sr. Director Clinical Operations (medical and quality management); Nursing Director Drug/Alcohol and Behavioral Healthcare Facility; Highmark Director Utilization and Case Management, and Director of Quality Improvement; Regional Manager Care/Case Management Capital BC; Crawford Regional Manager Worker s Compensation. Other management experience includes: Unit Supervisor Long Term Care; and Unit Nursing Coordinator Medical/Surgical VA Hospital; Compliance Director Landacorp (National Managed Care Software).
Healthcare Quality and Compliance JCAHO, URAC and NCQA accreditation, HEDIS, DOH, HCFA/CMS. Director of Regulatory Compliance with for national managed care software company; JCAHO and DOH compliance for Behavioral Health; Consultant - Healthcare and HIPAA Compliance.
Educator Present nationally on diverse healthcare subjects for utilization nurses, case managers, other healthcare professionals, and attorneys relating to medical/surgical, long term care, case management, risk management, legal issues, and quality improvement issues. Prior instructor for Accredited LPN Program. Published.
Owner/Consultant - Integrist Healthcare Consulting, LLC privately owned consultation providing Legal Nurse Consulting Medical-Surgical and Long Term Care Legal Consultation; Case Management Services; Healthcare Compliance Consultation, HIPAA Privacy Consultation, Training and Education; Case Management Program Development; National Level Healthcare Educator/Presenter
Sales and Marketing Quadrupled the client base for regional PA Worker s Compensation site to insurers/self payers and employers; sales of independent medical/quality/legal services
Clinical Experience Emergency, ICU, medical/surgical, home health, hospice, long term care, behavioral health, drug and alcohol care services.
Medical Management and Case Management Diverse care coordination experience including: Employer based and Independent Case Management Services, Disease/Condition Care Management; Utilization Management, Disease Management; Worker s Compensation; Case Management Services for Commercial, Medicare and Medicaid products.
Professional Employment Experience
BCNEPA Blue Cross North East Pennsylvania 11/07/2011 Present
Sr. Director Clinical Operations
Evaluated and implemented departmental improvements to improve quality and care cost outcomes
Exceeded annual cost savings goals
Coordinated NCQA strategy for achievement of HMO NCQA reaccreditation; First PPO NCQA accreditation
Proposed and implemented PCMH facilitation team
Created departmental value add positions including but not limited to Delegation Manager and Project Manager
Reorganized entire department to optimize quality, accreditation and care cost savings outcomes
Developed Transition of Care program
Implemented interventions to optimize regulatory and accreditation compliance, including but not limited to HEDIS outcomes, Delegation Oversight, Healthcare Reform, and state managed care mandates
Developed a proactive leadership succession plan and training
Developed departmental career ladder
Implemented aggressive cost savings interventions
Coordinated aggressive HEDIS improvement strategy
Coordinated Healthcare Reform mandates for QM and UM
Identified, tracked and trended utilization trends
Implemented appropriate cost savings interventions
Implemented new criteria and focus reviews to optimize care cost savings and minimize member liability
Implemented aggressive corrective action as accreditation risks identified
Promoted a departmental vision of best practice achievement through process improvement, stretch goals, staff development, and achievement of appropriate certifications
Developed and maintained aggressive UM and QM strategic work-plans ensuring timely milestone/outcome achievement and optimal measurable outcomes
Centene Corporation Absolute Total Care 03/22/2010 11/01/2011
Managed Care Organization/Medicaid
Manager of Case/Utilization Management
Revision and reorganization of case management program
Care coordination oversight and management of Case Management Team of RN Case Managers, Social Services, Program Coordinators, and Member Connections Representatives
Program coordination of Connections Plus Program Member outreach services
Quality and process improvement project coordinator
NCQA Accreditation 2010
HEDIS incorporation into case management
SCDHHS state audit 2010 and case management review
Program coordinator for special projects including but not limited to Hemophilia, Sickle Cell, High Risk OB, and other high cost and complex disease processes
Annual policy and procedure review and revision
McKesson 05/05/2008 03/17/2010
Community Based Field Case Manager/Medicaid
Disease management services and care coordination for Pennsylvania Medicaid members
Provider education and assistance with care coordination for patient members
Analysis of care options, implementation of individualized education strategies and fluid measurement of member outcomes
Cove Forge Behavioral Health White Deer Run Williamsburg, PA 11/01/2005 05-02-2008
Director of Nursing 170 bed facility
Nursing Director Adult Rehab/Detox and Residential Treatment Facility
Community Liaison
Compliance - PA and Federal Behavioral Health Regulations; JCAHO Accreditation and DOH surveys
Departmental Quality Improvement and Protocol Development
Coordination - Staff Development and Client Education
Risk Management/Safety Committee/Project Management
Capital Blue Cross Allentown Regional Office of Harrisburg, PA
Regional Manager of Care and Case Management 02/2005 10/2005
Care and Case Management of NE Region for commercial and Medicare members
Case management system program development
o Software Vendor - TriZetto ClinicalCare Advance
URAC DOH CMS NCQA Accreditation
Discharge Outreach Program
Utilization and cost management
Budget development and management
Staff development and training
Greater Altoona Career and Technology Center Altoona, PA
08/2004 02/2005
Program Director New Choices/New Options
Instructor Medical Assistant Curriculum/HIPAA Privacy
Integrist Healthcare Consulting, LLC. Pittsburgh/Duncansville, PA
Legal Nurse, Case Management, and Compliance Consulting Services 2000-2005
Legal Nurse Consultant
Review and Analysis of Medical Records Comprehensive Reporting
Medical Malpractice, Managed Care, Personal Injury, and Criminal Litigation Assistance
Case Management and Elder Care Management Services Consultant
Case Management Services Health and Workers Compensation Care Coordination
Care Coordination Services Elder Care Coordination Long Term Care Coordination
Education
HIPAA Privacy, Case Management , Medical/Legal
Practice Management Consultant
Acting Director
Compliance Consultant
HIPAA Privacy Services, URAC Case Management Services
Physician NCQA Credentialing and HEDIS Services
Landacorp, Inc. - Atlanta, GA 2000-2001
Medical Management Software Company (Laid off 1-4-2001)
Director of Regulatory Compliance
Research, analyze and incorporate all pertinent regulatory and accreditation standards into internal policies, procedures and training manuals and client education programs
Compliance expertise included URAC, HCFA, JCAHO, DOH, and HIPAA regulations
Highmark Blue Cross and Blue Shield - Pittsburgh, PA 1995 - 2000
Managed Care Organization
Director of Quality/Compliance Healthcare Services
Accreditation/compliance management pertinent to utilization review and case management processes for HCFA/QISMC, NCQA, URAC, and DOH with 5 years of accreditation success.
Director of Care and Case Management
Developed and managed care/case management division, including: Medicare +Choice, Behavioral Health, Commercial, National, and Quality Improvement units, including 300 employees
Case Management Program development - Landacorp
Implemented Provider Education and Disease Management Programs
Coordinated Staff Education/Case Management and UM Certification Programs
Achieved successful HCFA, NCQA, DOH and URAC accreditations
Appointment to URAC Commission for the development of National Case Management Standards
Regional Director of Care and Case Management
As above on a regional level
Crawford HealthCare and Rehabilitation Management - Altoona, PA
1990 -1995
Worker s compensation, healthcare, and disability case management organization
Consultant-in-Charge/Regional Manager
Provided oversight and management of case and vocational consultants
Case Management worker s compensation/health
Sales and marketing to new and existing accounts
Prepared cases for litigation and assisted in deposition preparation
Valley View Nursing Home Altoona, PA 1990
Long-term care facility
Education and Quality Improvement Coordinator
Developed staff education program and facility policies , Assessed and measured quality of care in accordance with DOH requirements
Coordinated and instructed nursing aid certification and training
Veterans Administration Medical Center Altoona, PA 1983 1989
Federal Veterans Administration Hospital
Utilization Review and Quality Improvement Coordinator 1987 1989
Utilization review, Quality Improvement and Staff Education
In-service Coordinator 1985 - 1987
Staff education, annual review compliance, program development, career advancement committee
Surgical Unit Staff and Head Nurse 1983 1985
Additional Professional Experience
Clinical - Emergency, Medical, Surgical, and LTC
Nursing Education/Instructor
Hospice/Home Health Care
Health Insurance/Sales
Sales/Marketing
Education
BSN Nursing - Pennsylvania State University, State College, PA 1975
Masters in HealthCare Administration Incomplete - California College for Health Sciences, 222 W. 24th St., National City, CA 91950 Completed 15 Credits 1999
Professional Certifications
Certified Case Manager: 1993 Present
Certified Legal Nurse Consultant: 2001 2006
Certified Managed Care Nurse: 1996 - 2006
Publications
Appointed to editorial board of Case in Point August 2013
Case in Point Fortifying Powerlessness Managing Unmanageable Lives, December 2007
ADVANCE Case Management and HIPAA June 2001
ADVANCE - The Ying and Yang of Case Management Balancing Cost and Quality September 1999
ADVANCE Case Management Opportunities in Managed Care January 2002
ADVANCE Case Management Outcomes March 2002
Journal of Care Management HIPAA A New Protected Species July/August 2001
Bimonthly Newsletter - Integrist Healthcare Consulting, LLC
West Allegheny Magazine Regional Pittsburgh Magazine How to Select a Nursing Home July/August 2001
HIPAA 101 Cool Tools Web-Based Program PRIME
Author/Continuing Care Case Managers: Planning for Life through Life Care Planning December 2002
Inside Case Management Just Do It HIPAA Privacy January 2003
Discharge Planning Marketing with HIPAA Fall-Winter 2004
Editor Lippincott and Williams - 2003 to present
Editor PRIME - Continuing Education Courses 2002 to present
Presentations
Speaker Wyeth Pharmaceutical Conference Case Management and Patients with Depression September 2008
Speaker - CMSA June 2005 - The Role of TNF Modifying Agents in the treatment of Rheumatoid Arthritis
Speaker: MOSBY Case Management Conference November 2003 Presentations: Case Management and HIPAA and Case Management Malpractice and Litigation10/14/2013
Speaker: General Topics include: Case Management Issues, HIPAA Privacy, Clinical, and Medical-Legal Case Issues
Speaker: NBI (National Business Institute) Nursing Law Update Seminar - Universal Healthcare Issues and Current Legal Issues in Nursing
Speaker: NBI (National Business Institute) Medical Record Review and Analysis for Attorneys
Speaker: DUPONT National Case Management Presenter (Deep Vein Thrombosis) - 2000 thru 2001
Speaker: NBI (National Business Institute) - Nursing Home Negligence November 8, 2002
Speaker: NBI (National Business Institute) Medical Record Review for Paralegals
Speaker: Lorhman Institute - HIPAA Privacy for Healthcare Professionals
Speaker: CMSA Annual Seminar and Nationally Legal Issues and Case Management
Speaker: PRIME, INC. - Low Back Pain Case Management, Rheumatoid Arthritis and DVT National Presenter
PRIME, INC. Program Development Editor and Speaker
PSNA Speakers Bureau 2001
ASPE American Society of Professional Education HIPAA Privacy Compliance
Educator: Community College of Allegheny County Part Time Case Management Certification Instructor
Educator: HIPAA Privacy Workshops Altoona Career and Technology Center
Speaker: Centacor Managing Rheumatoid Arthritis
Auditor: Perigee Healthcare Consulting NCQA Physician Office Assessments/Health America Client
Auditor: Outcomes, Inc NCQA Physician Office Assessments/Health America Client
Case Manager Subcontractor - Nation s Care Link Long Term Care Nurse Assessment Subcontracting Services
Case Manager Subcontractor - Bunchcare and Associates, Inc Case Management Services Tail Claims
Advisory Committees
GENENTEC Advisory Committee National Case Management Committee 1998 - 1999
SANOFI Advisory Committee National Case Management Committee 1999
STADTLANDERS Advisory Committee National Case Management Committee 1999
CMSA Pittsburgh Chapter Member and Education Committee 2001
URAC Case Management National Advisory Committee - 1998
URAC (National) Education Advisory Committee- 2000
CMSA (National) Nomination Committee - 2000
CMSA Special Interest Group (Acute Care) Moderator 200l
CMSA Acute Care (SIG) Leader 2001 2002
Blair County Chamber of Commerce - Health and Safety Committee 2002-03
Professional Organizations
Case Management Society of America (CMSA)
National Association of Manager Care Nurses
References available upon request
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