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Click here or scroll down to respond to this candidateCandidate's Name , M.S.M, R.N., CCMStreet Address Spring GlenShelton, CT., Street Address
PHONE NUMBER AVAILABLEEMAIL AVAILABLEOver thirty years of healthcare experience establishing expertise in nursing, case management and teamwork. Exploring career advancement opportunities where my education, skills and experience can be utilized to a mutual advantage. Greatly interested in UM, Appeals and Auditing for exceptional processes. I have worked in both the Managed Care arena and the Hospital setting.PROFESSIONAL EXPERIENCE:Interim Remote Denial/ Appeal Nurse for Baton Rouge General Hospital2023Reviewed hospital medical records- ED, OP surgery IR procedures that were denied for medical necessity and appealed denied cases to the insurer. Audited the use of correct usage of InterQual and MCG criteria by the UR nurses.Interim UM nurse for Virginia Mason Franciscan Health, Tacoma, WA.Remote 2023Reviewed hospital medical records and organized UM clinical information which was then submitted to the insurers.Interim Appeals nurse (remote) for Washington Hospital Fremont, CA.Remote 2023Interim Director of Case Management at Tuba City Regional Health Care in Arizona2021-2022ECHN Manchester Memorial Hospital and Rockville General Hospital2018- 2021Administrative Director of Care ManagementManage and Support 17 employeesClinically support my team by doing clinical reviews daily for 6 months to ensure discharge planning is timely and patients are transitioned safely and efficientlyPerform clinical audits for Compliance purposes.Completes and monitors monthly Case Management Dashboard and statistics.Completes daily clinical reviews for Commercial insurers.Constellation Home Care, Orange, CT. 2017-2018Created and completed Emergency Preparedness Policy and Procedure Manual. Reviewed charts and performed audits and appealsNew Britain General/ Midstate Hospital 2015-2017Director of Case ManagementsDirected and supported staff of 12 in both hospitalsMentored and trained new staff in Utilization ReviewAssisted in doing UR to support medical necessity of hospital staysManaged budget effectivelyFocused efforts on continuous improvement with the desired outcome: cost efficiencies, quality care and client satisfaction.Western Connecticut Health Network, Danbury Hospital 2007- 2015Director, Clinical Resource ManagementDirects staff of 38 employees ( 22 nurses, 9 social workers, 5 front office staff and 2 supervisors.Monitors all hospital stays as to medical necessity, length of stay, identification of high risk patients, and effective discharge planning.Responsible for the formation of a multidisciplinary committee to review cases with patient / family discharge barriers.Ongoing review of workflows and processes in an effort to improve efficiencies.Delegation of work assignments to staff and the evaluation of staff performance for 11 direct reports with input on others.Manages an operating budget of $ 3.1 MFocused efforts on continuous improvement with the desired outcome: cost efficiencies, quality care and client satisfaction.Health Net, Inc., Shelton, CT 2006 2007Manager, Care ManagementManages in a team environment 3 Homecare nurses, 1- Concurrent review nurses for Skilled Nursing Facilities, 1 Regulatory Compliance Nurse and 4 CoordinatorsUsing Inter Qual criteria, guide the clinical staff in performing utilization review for homecare requests and appropriate medical stays in Skilled Nursing Facilities.Prepared monthly reports for the Vice President of Medical Management.Pitney Bowes, Shelton, CTManager, Absence Management Department 2004 2006Managed a team of 5 nurses and 3 claims examiners who oversee all Short and Long Term Disability cases, FMLA Personal Leaves of Absence and Workers Compensation Supplement for PB employees nationwide.Initiated the increased scope of case management practice which entailed Communication with Health Plans nationwide to ensure continuity of care.Greenwich Hospital, Greenwich CTManager, Case Management Review 2002 2004Managed and work in a team environment with the staff of 13 (case managers and social workers) performing utilization management and discharge planning.Initiated the following of high risk patients throughout the continuum of careGreenwich Hospital, Greenwich CTUtilization Clinical Coordinator 2001 2002Review all inpatient denials and appeal cases to the insurers.Implement educational presentations for physicians and case managers.Reinforce Inter Qual criteria/consultant to case managersPHS Health Plans/HealthNet, Shelton CTDirector of Care Mgmt., Program Development CT 2001 2001Directed staff of Care Managers to oversee the outsourcing of Disease State Care Management, covering neonatal, CHF, diabetes.Created clinical programs to meet the needs of members under care management .Identified related trends and improved care management, while capitalizing on cost efficiencies, prepared, tracked and controlled operating budget, developed and/or adopted disease or condition specific clinical pathways for care management team.Planned and implemented quality assurance procedures to ensure strict adherence to clinical pathways and standards of healthcare excellence.Focused efforts on continuous improvement to maximize cost efficiencies, quality care and client satisfaction.Tri-State Case Management NY, CT and NJDirector 1999 2001Directed a staff of 40 case managers and four direct reports.Oversaw case management for catastrophic and high risk pregnancies.Managed an operating budget of $2.2M.Maintained complete continuum of care, including hospital, home care, rehabilitation and patient education.Developed and implemented quality assurance practices to ensure compliance with healthcare standards of excellence.Retained 90% of staff in an industry with high staff turnover rate.Tri-State Case Management NY, CT and NJSenior Utilization and Case Manager 1997 1999Responsibilities included direct supervision of 29 case and utilization managers.Monitored all hospital stays to justify length of stay and complete continuum of care, discharge planning.Delegation of work assignments to staff and evaluation of staff performance, compliance with regulatory requirements, quality assurance, review of all patient documentation, identification of third party liabilities.Ongoing review of workflow and processes to recommend and improve efficiencies.Functioned as Lead Trainer for new staff and satisfied all criteria during recent audit.Tri-State Case Management NY, CT and NJCase Manager 1994 1997Maternal/Child, High Risk Maternity, Pediatrics and GeneralOngoing interface with physician, primary care nurse and patient to monitor overall progress of treatment.Utilization review of high risk (birth to 3) and establishment of plan to carePreparation of reports on patient surveys and outcomes for quality assurance.Tri-State Case Management NY, CT and NJUtilization Review/Medical Care Coordinator 1992 1994Responsibilities included on-site review of medical records to establish criteria for continual hospital stay.Education:Masters Degree in Management 2002Albertus Magnus College, New Haven, CTBachelor of Science in Health Studies 1990Charter Oak College, Farmington, CTNursing Diploma, St. Vincents Medical Center, Richmond, NYLicenses:Registered NurseState of ConnecticutState of WashingtonState of LouisianaCertified Case Manager |
