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Click here or scroll down to respond to this candidateCandidate's Name
OBJECTIVEA managed care position with an organization where my knowledge and skills will have animmediate impact on corporate vision, values, profits, and productivity.SUMMARY OF QUALIFICATIONS* Over 25 years of Step-Down Telemetry, Ventilator Care and Neonatal Intensive CareUnit nursing care experience at Rush University Medical Center, combined with over 20years of Utilization Management, Quality Improvement, Claims Management, CaseManagement and Disease Management experience for local and nationally knownindustry leaders.e Experience with major hospital institutions and managed care organizations,collaborating in the execution of health development strategies that leverage healthindustry trends to meet business, financial and technology requirements.PROFESSIONAL EXPERIENCEHealth Care Service Corporation August 2021 to PresentClinical Delegation Coordinatore Participates in delegation oversi;Reviews the processes utilized byand accreditation standards.e As in the review of the Utilization Management policies of the medical groups to ensure thatthey are following the current Utilization Management Plan.ht audits for assigned Medical Groupsigned medical groups to ensure compliance with regulatoryPalos Community Hospital July 2016 to PresentEmergency Room Case Manager Utilize computer-based system (Epic) to gather information for reviews and makereferrals to the healthcare providers Utilizes established medical necessity criteria (MCG Health) to conduct screeningfor medically appropriate admissions and Observation stays. Identify and work to alleviate a variety of social issues, utilizing outside resources and programswhen necessary and appropriate.Mt. Sinai Hospital December 2011 to 2014Lead Disease Managere Reported to the Vice President of Quality & Safety, with full responsibility for 8 FT!Provided direct leadership and education to office-based clinical and non-clinicaproficiency, independence, and productivity.e Developed and implemented an inpatient disease management program related to the manaof Diabetes, CHF, COPD and Asthma patients, which led to the hospital Medicaid readmissirates being below the national norm over a 9-month period. Collaborated with the IT staff to develop enhancements for the disease management database tofacilitate productivity and better serve the client base.McKesson Corporation, Wheeling, IL August 2006 to May 2011Hospital Based Case Management, Manager/Project Managere Reported to Regional Vice President of Patient Care Services, with full responsibility for 8 remoteregistered nurses who worked to improve self-management abilities of 280K Medicaid enrolleesfrom Chicago to East St. Louis while reducing their inpatient and emergency room utilization viause of InterQual. Criteria* Developed and implemented strategic processes to ensure achievement of establishedorganizational metrics, member enrollment and participation rates for the State of IllinoisMedicaid beneficiaries. Achieved measurable success in a collaborative effort with the program managers which resultedin the State of Illinois saving approximately $560 million over the 5-year contract period.Apogee Health Partners, Chicago, IL March 1999 to July 2016Director Utilization Management /Quality Improvement- Consultant Ensured implementation of proper utilization and quality management processes; directed ongoinginternal review of organizational compliance with NCQA, URAC, HEDIS. Superior clinical skills to determine appropriate clinical information for medical necessity utilizingApollo Medical Review Criteria Guidelines, Implemented and managed procedures and processes to ensure compliance with federal and stateregulatory requirements, making quality improvements as requested via internal and externalconstituents Composed and presented monthly and annual managed care reports for compliance review+ Accountable for evaluating and collecting medical record information from contracted Providersin a HIPAA compliant manner.EDUCATIONMaster of Science in Management and Human Resource DevelopmentNational-Louis University, Chicago, ILBachelor of SeCreichton [Jniversity Omaha NE |
