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Click here or scroll down to respond to this candidateCandidate's Name
High Bridge, New Jersey EMAIL AVAILABLE Cell Phone - PHONE NUMBER AVAILABLEPROFESSIONAL SUMMARYI am seeking an exciting opportunity in a healthcare company or the pharmaceutical industry where my extensive clinical healthcare background relates to quality documentation and clinical reviews of large data files.PRODUCT, REGULATORY & OPERATIONAL EXPERIENCEPayer ProgramsMedicare ProtocolsNo-FaultPopulation Health Management:oQuality/Risk ManagementoUtilization Management Perspective, Concurrent, and Retrospective Reviews (Ten Years Experience)oCase/Disease ManagementoCare Coordination Regulatory:oTrained by civil trial attorneys on medical malpractice Laws and medical chart review for causation in National and State (NY & NJ) Malpractice law.oKnowledge of Medicaid laws related to DOHHS, AHA, CMS, MACs, OIG, and NCHSoCoding rules are about outpatient clinics, private practice, and inpatient settings.oCPG, URAC, NCQA, HIPAA and OSHAoPerformed Pharmacy Co-vigilance - Patient Adverse EventsoNational Standards of Care for various disease initiatives through DHHS, CMSoNCQA, URAC rules and all federal and state pharmacy compliance regulations.TECHNICAL EXPERIENCEEncoder Pro, QCIS, periscope, QNIX, CCA and Pega.Med CaptureMed Decision/Care PlannerCosmosHTAAtlasCPWJabberPyramidISTOn-Base Tru CareMcKessonNICEPIC Case ManagementEPIC Elbow SupportEPIC clinDonEPIC Secure ChatPractice Fusion Elbow SupportUniflowCCMS, SQL, SASFacet, MacessMedi TrackCare OptimizeDIAMONDBENAdvancerCPS, MAPP, UNICONMHSUNET, Jabber, Microsoft TeamsKDJ, ECAA, PSYCKESNavientEPaces, ECG, Citrix, Hot Spotting ImpactPCS, ICUEMDA/REEDSCCPRO & 3D AnalyticsCCM Platform DesignsProcess Improvement Workflow DesignCommunity Care LegacyTableau Care OneMicrosoft Office SuitePROFESSIONAL EXPERIENCELancesoft Inc. Virginia state 4/14/2024 5/14/2024Clinical Review Consultant:Prospective, impatient Concurrent reviews for intensive care critical Caremed-surgical patientsPre-authorization, PCA, CDPAP home Care ServicesOutpatient TREATMENTServices and DME Cases.30 day Training on MCG, Molina Healthcare Policy Guides, Vendor Guidelines.IndependentPatient Care Advocate Consultant February 2023 to PresentReceive community referrals.Assist Medicaid recipients with navigating our healthcare system.Connect Patient and Primary Care Physicians to close gaps in care.Meet with Managers at Skilled Nursing & Rehabilitation facilities to facilitate timeliness of care.Report patient complaints to senior management.Educate Skilled Nursing Facilities about the Center for Medicaid/Medicare Triple Aim TheoryEducate patients and facilities about HIPAA and patient rights.Educate providers regarding documentation and the law.Explain the importance of medication reconciliation.Encourage yearly wellness examinations and three-month chronic care follow-up visits, if the patient has two or more co-morbidities.Encourage patients to keep a diary to ensure that they keep track of their medical appointments.Educate patients about the importance of tracking diet habits, blood pressure, blood sugar and weight.Encourage patients and or care givers to be part of their healthcare team.Provided community resources as it pertains to medical transportation, local food banks and free clothing.Atlantic Health System/Talent Software ServicesCASE MANAGEMENT CONSULTANT November 2022 February 2023Performed patients assessments and facilitated the discharge planning process for levels of care Intensive care critical Care and med surgical units.Educated inpatient case managers about CMS Triple Aim TheoryDeveloped a multi-disciplinary, culturally appropriate, age-specific discharge plan.Assessed and documented patients SDOH for additional care needs.Used the EPIC EMR system for documentation, electronic communication, and secure chat.Performed Initial and continued stay reviews.Used Milliman Care Guidelines and medical decision making.Attended and participated in medical and continued stay rounds.Collaborated with the care team about complex cases.Initiated case and disease referrals to facilitate transitional care.Facilitated transitional care for private pay patients and provided patient education.Initiated homecare services, durable medical equipment, IV infusion and enteral feeding.Educated patients about universal precaution, importance of having a primary care physician to promote annual wellness, chronic care management visits and self care monitoring.Presented and discussed New Jersey State and NCQA HEDIS star quality measures (AAP_ Adult Access Preventive Ambulatory Care and Transitional care_ TRCUnited Health Care Group.HEALTH HOME TRANSFORMATION CONSULTANT February 2022 September 2022Responsible for the Institution for Family Health (IFH), Hudson Valley Coalition (HVC), Childrens Health Home Upstate New York (CHHUNY), ONODAGA, and New York Community Health Home (NYCHH)Accountable for successful deployment of UHCs Clinical Support program at the practice level, including but not limited to, introducing and educating practices on the value/use of reporting tools, patient registries and delivery of reports via UHCs Technology Portals Build and effectively maintained relationship with the practice leadership and key clinical influencers actively involved in practice transformation.Regularly facilitate efficient, effective practice improvement meetings with the practice to monitor, present, and discuss progress on the transformation action plan and achievement in milestones.Developed strategies based on performance analysis, for improvement that includes specific outcomes and metrics to monitor progress to a goal and make recommendations for improvement.Designed practice transformation action plans and implemented appropriate performance improvement initiatives designed to assist the practice in achieving contractually required transformation milestones.Monitored and reviewed the progress of the practice in milestone achievement and ensured the practice is accountable for successful completion Where outcomes are below goal identified outlier member files for focused action plans.Audited Health Home assessments and member care plans to ensure compliance with regulatory requirements.Use data to analyze key cost, utilization and quality data and interpret results to assess the performance of the practice.Used data to analyze trends and work with stakeholders to agree on and implemented proactive strategies to address issues, and measure impact using a Plan-Do-Study-Act (PDSA) rapid cycle improvement approach; including external practice data Educated & Deployed technology tools to support Practice TransformationBuild and effectively maintain relationships with. team members in the UHC Clinical organization as well Medical Directors, local Network leads, Health Care Economic Analysts and Clinical Analysts in support of the program Consult and partner with internal UHC matrix partners and the practice to identify organizational and structural challenges hindering achievement of desired program outcomes.Collaborated with UnitedHealthcare teams including the Practice Care Coordinators, quality management teams, hospital clinical teams, behavioral health teams to support whole person care for our members with practices and hospitals.Assisted and supported department leaders in summarizing and disseminating experience related learning by way of team updates, written reports / articles, and / or presentations as called for by directors.Ensure all required member documents as indicated in the Community and State UnitedHealthcare contract for Health Home programs.Monitored ER and IP utilization and to ensure the timeliness of care coordination and discharge planning efforts.Referred Medicaid member to Home Community Based ServicesPerformed Chart Audits, participated in Integrated rounds and followed up on Interdisciplinary Team meetings.Receive and transmit ADT, member roster, member data and gaps in care reports.Integrated Resource Inc. Temporary ContractEMBEDDED CLINICAL QUALITY IMPROVEMENT LIAISON ANALYST January 2021 January 2022Assigned to both ACOs Atlantic Health Systems and Optimus Healthcare (30+ practices).Primary liaison for the Customers quality management department and assigned provider groups to improve HEDIS and Stars quality performance.Support Customers change management that will impact the quality of care provided in practices.Monitor and analyze provider quality performance reports. Identify areas of improvement, aid with root cause analysis, assist with developing solutions, and develop a work plan to monitor progress.Conduct provider on-site visits on a regular basis, as mutually agreed, to implement a work plan and to conduct provider education sessions regarding appropriate coding practices and chart documentation.Assist with coordination of care for identified outpatient members/patients (telephonic or face-to-face member contact, schedule preventative appointments or follow-up evaluations, confirm with patient if prescribed medications are as directed, and update the patients medical record with current information as appropriate.Assist discharged members/patients with transition of care process, by contacting patients within 24-48 hours after discharge to schedule follow-up with the primary care physician, confirm with patient if prescribed medications are being taken as directed, educating members/patients about health care system services available, confirm hospital records are received by the provider/practice and updating the patients medical record with current information as appropriate.Update the patients medical record with recommendations from member/patients specialists as appropriate.Collaborate with value- based programs and provider contracting and services to manage provider quality performance.Share available Customers community services and resources with the providers/practices.During HEDIS season, assists with the retrieval of charts, chart abstraction, and chart review entries.The clinical quality measure will adhere to the HEDIS guidelines for chart review abstractions and standards.Provide HEDIS provider guidelines highlighting appropriate HEDIS codes for claims submission.Assist with optimizing the use of the practice's electronic medical record (EMR) system to close care gaps; and assist in the development of new strategies for member/patient and provider outreach, engagement, and education materials to improve quality performance.Oversight leader for quality governance committee.HealthecPOPULATION HEALTH/MANAGER OF CARE COORDINATION April 2017 January 2020Responsible for all front-line patient/provider engagement initiatives for AICNY LLC (The Alliance for Integrated Care of New York) a CMS-approved Accountable Care OrganizationEfforts resulted in cost- savings of $2 million/year for the ACO.Direct Responsibilities for the ACO included:oReducing healthcare utilization/cost on top 5% high-risk Medicare beneficiaries and improving patient outcomesoCaptured CMS and NCQA clinical quality-measure data.oQuality Data Analytics and Practice TransformationoSuccessful risk management and cost-containmentoStrategic attribution managementoDevelop client strategies and processes that align with CMS, NCQA and PCMHoCreated corrective action plans for improvement across the ACO.oCommunicate with hospitals regarding discharge planning, primary care follow-up readmissions mitigation.oCreated CCM (Chronic Care Management) program and AWV (Annual Wellness Visit) initiatives for private practices and their high-risk patients.Create and manage marketing blog for Health ECClient presentations on care-coordination initiativesParticipate in forums, to identify and articulate trends in healthcare reform.Use of HealthEC Population Health Management (PHM) platform to educate providers, nurses, and administrative staff on how to effectively utilize HealthECs digital platform.Train new hires as care coordinators:oData analyticsoCare coordination.oPractice transformation.Aerotek/EXL Healthcare - Amerihealth (Contract)PHYSICIAN ENGAGEMENT NURSE June 2016 April 2017Responsible for physician engagement throughout Camden, Mercer, Gloucester and Burlington countiesScheduled 4 to 5 practice visits/day to provide cost comparative reports for primary care and specialist providers.Delivered AmeriHealth plan value -based care initiative to practice gatekeepers.Reviewed physician reports (i.e., gaps in care, ER/hospitalization utilization and generic drug substitution)Participated in HEDIS audits, chart reviews, overreads, CDC CBP AWC measures.Engaged providers in cost-containment initiatives.Escalated provider complaints to provider relation representativesDocumented and reported suspicious activity via fraud-line and prepared corrective action plan reports.Paragon Search & Strategies, LLCSENIOR PROJECT HEDIS NURSE February 1989 June 2016Clients Included:oHealth FirstoAffinity Health PlansoAqurate Health Data Management Inc.oUnited HealthcarePerformed medical chart reviews, data extractions.Responsible for overreads for HEDIS via Altegra Inc., Med Captured tool, QHRS, and Record FlowMedical record audits and compliance:oDocumented events in accordance with NCQA regulationsoUse random patient samples to verify ICD9/10 and CPT coding errors.Educated providers on proper coding and its impact on their revenue stream.Educated private practice and institutional provider on NCQA, fraud and compliance education.Escalated insurance claims to managementParticipated in HEDIS reporting requirements and created a process improvement workflow design.Mentored and trained new hires system applications, share drive, mapping, SOPs, Web Ex claim database, excel, outlook tools as well as NCQA guidelines and measures.Independent ContractorNURSE CARE ADVOCATE FOR CMS MEDICAID BENEFICIARY (REAL WORLD CASE PROJECT May 2015 November 2015Documented patient complaints, history & physical and treatment plan.Assessed patient socioeconomic status and made social service referral to initiate completion of documents in lieu of SSI Disability insurance determination.Provided community/private resources for temporary support.Identified gaps in and continuity of care.Encouraged Primary Care Physician and care team follow up visits.Filed provider complaint with CMS and Division of Health Human Serviceschallenges with accessoTimeliness and assessment of care which caused frequent ER visits and hospitalizations.oSuccessfully navigated patient healthcare accessoAssists patients with enrollment into health plan case management program.oResearched and procured a new PCP provider.Contacted PCP and care-team specialists to develop care-plans and assist with coordination of care.Transported patients to/from medical appointments and local food banks.Provided continuous patient education.Partners In Care, INC.NURSE CARE COORDINATOR December 2008 November 2014Responsible for healthcare cost reduction through better care coordinationPerformed assessment of claims data to identify:ogaps in careohospital frequent flyersoover/under utilization of care serviceMedicationCase and Disease Management servicesFormulated effective care plans to improve positive clinical outcomes.Researched and reported medical adverse events and medication contraindications to Quality Review Board and networkManaged 500+ cases while maintaining production yield of 90% for multiple clients, including:oAetnaoHorizon BC/BSoCignaoMedicare ACOoSelf-insured plansInitiated Six Sigma projects in multiple disease states using PDCA (plan do check act) tool, including pediatric obesity and early pediatric diabetic screening.Led process improvement project initiatives used DMAIC (Define Measure Analyze Improve Control) tool.Participated in Cigna Health utilization board meeting.Served on Companys quarterly (SME) Quality Performance Board Committee:oReview standards of careoClinical practice guidelinesoPatient- provider issues and complaintsDeveloped and maintained relationships with staff and physicians.Effectively worked with PIC Medical Director and Pharmacist to drive improved clinical outcomes and overcome barriers to care.Provided lead generation to the Senior Network Account Manager for recruiting into the (UMG) United Medical Group provider network improvement.Enhanced initiatives via practice onsite visits to communicate MDs, NPs, PAsoClinical documentationoClinical practice SOC guidelinesoTermination of care protocolsoPatient outreach protocoloPatient education handoutsoComplex patient care-plansNew York Presbyterian/Weill Cornell Medical CenterCOMPLEX/CATASTROPHIC MEDICAL/HIV AIDS/DIABETES NURSE CASE MANAGER (TELEPHONIC) August 2005 - November 2017Tracked and monitored care management services to ensure that evidence-based-medicine protocols were provided to all patients.Performed case/disease management for Managed Medicaid patients.Focused care coordination to reduce ER visits/hospitalizations.Initiated HIV/AIDS disease management program.Coordinated discharge planning and authorized medically necessary treatments.Performed (concurrent/ancillary) reviews.Authorized treatment care services based on medical necessity and payer coverage.Performed medication utilization and reconciliation.Performed retrospective claims analyses for hospital in/out-patients and physicians to verify proper coding protocols.Supported and mentored teams in the Medical Management Division on Milliman Care Guidelines and Interqual medical necessity criteria and clinical practice guidelines in accordance with various chronic disease statesAttended leadership workshops and cultural competency seminars.Participated in Six Sigma projects.EDUCATION AND TRAININGUnion County CollegeDIPLOMA IN NURSINGKatharine Gibbs Business SchoolBUSINESS CERTIFICATEAmerican Society Legal Nurse ConsultantCERTIFICATIONNew Jersey License Life and Health ProducerDlsi Professional Coder ProgramCertified Quality Six Sigma Green BeltNEW JERSEY HOSPITAL PRE-ADMISSION TESTING PROJECTNew Jersey License No. 26NP03325300 Expiration 5/31/2025New York License No. 2167812 Expiration 2/28/2026Pennsylvania License No. PN302946 Expiration 6/30/2024Certified in Fraud, Waste, and Abuse (FWA)References Upon Request |
