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Click here or scroll down to respond to this candidateCandidate's Name , MSN, RN, CCM PHONE NUMBER AVAILABLE EMAIL AVAILABLEBrownstown Township, MI LINKEDIN LINK AVAILABLE REGISTERED NURSE UTILIZATION MANAGEMENTAccomplished RN with 20+ years of experience in healthcare, care management, and utilization review. Ensure health care services are administered with quality, cost efficiency, and compliance. Utilize clinical experience and skills in collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for patients. Specialize in HEDIS measures. Excellent organizational, leadership, problem-solving, critical thinking, and analytical skills. Able to adapt quickly to change and work effectively in fast-paced environment. Team oriented with a positive attitude. Open to opportunities in Metro Detroit or Ann Arbor. Prefer remote or hybrid positions. Willing to travel. QUALIFICATIONSAcute Care Clinical Nursing Data Management HEDIS Motivational Interviewing Medical Terminology Compliance Reporting In- and Out-Patient Care Home Health Care Risk Management Quality Assurance Utilization ReviewSKILLSWritten and Verbal Communication, Collaboration, Strategic Planning, Negotiation, Interpersonal, Time ManagementWORK HISTORYTENET HEALTH 12/2024- CurrentTRANSFER CENTER REGISTERED NURSEFacilitate patient transfer from outside facilities to Tenet Health hospitals.Facilitate physician to physician consult requests.Arrange PANDA transport for patients from outside facilities.Act as a liaison to colleagues.Convey pertinent patient information and needs with leadership. BLUE CROSS BLUE SHIELD OF MICHIGAN (BCBSM) 07/2014 07/2023 BLUE CROSS BLUE SHIELD OF MICHIGAN-REGISTERED NURSE TEAM LEADER Perform all duties as Registered Nurse Supervisor, as well as the following: Identified and addressed employee performance; promoted employee professional development. Acted as advocate for patients that ensured theyre receiving safe, state-of-the-art health care. Networked with BCBS organization; became liaison between patients and physicians. Participated in work groups and project assignments. Provided successful leadership that ensured direct reports meet metrics. Candidate's Name , MSN, RN, CCM 810-650-2283 EMAIL AVAILABLE PAGE 2 OF 3 EMERGENT HOLDINGS-REGISTERED NURSE CARE MANAGEMENT SUPERVISOR Reviewed quality of registered nurse care manager and care management specialist work. Focused on NCQA standards compliance and HEDIS measures. Identified and addressed employee performance; promoted employee professional development. Completed yearly performance evaluations for direct reports; reviewed and analyzed weekly data reports. Organized weekly staff huddle, manager meetings, conducted 1:1 meetings, and attended upper leadership meetings. Created job requisitions, reviewed resumes, scheduled interviews, interviewed candidates, and hired staff. Corresponded with suppliers and Contingent Labor team; interacted with IT and HR business partners when needed. Organized and attended monthly Integrated care conferences. Collaborated with ancillary staff, including medical doctors, social workers, pharmacists, and dieticians. BLUE CROSS BLUE SHIELD OF MICHIGAN -REGISTERED NURSE CARE MANAGER Aimed to reduce hospitalizations, emergency room visits, and hospital readmissions; optimized patient health outcomes in attempt to increase organization ROI. Assessed, planned, implemented, and monitored goals that were established for patients through comprehensive health assessment; continually evaluated goals that promoted cost efficient and quality outcomes. Coordinated services for patients, including medical, behavioral, social, dietary, pharmacy, and physician consults.BLUE CROSS BLUE SHIELD OF MICHIGAN- REGISTERED NURSE CARE MANAGER CONTRACTOR Oversaw care management of coordination of care and payment of service patients. Acted as Advocate for patients and ensured they received safe, state-of-the-art healthcare; optimized patient health outcomes; reduced hospitalization and readmissions; educated patients on appropriate levels of care. Networked within the BCBSM enterprise; participated in work groups, project assignments, and Inclusion and Diversity events; created inclusive work culture. Assessed, planned, implemented, and monitored goals that were established for patients through comprehensive health assessment; continually evaluated goals that promoted cost efficient and quality outcomes. Coordinated services for patients, including medical, behavioral, social, dietary, pharmacy, and physician consults.CAREER ACHIEVEMENTS Managed clinical/non-clinical staff who needed to meet annual corporate metrics. Provided hands-on leadership through consistent meetings, open communication, care auditing, and constructive feedback. Resulted in 100% direct reports successfully meeting annual goals/metrics. Candidate's Name , MSN, RN, CCM PHONE NUMBER AVAILABLE EMAIL AVAILABLE PAGE 3 OF 3 BCBSM lost a half-Star rating from 4.0 to 3.5 Stars to its PPO health insurance plan that led to multi-million-dollar loss in revenue. Managed team that closed patient gaps in care/HEDIS measures, promoted customer satisfaction, encouraged peer-to-peer care reviews, collaborated with leadership and physicians for resolution of patient issues, and participated in work groups. Resulted in gain in Star rating from 3.5 to 4.5 which was financial win for BCBSM and its patients. Inappropriate ER visits and hospital admissions/readmissions needed to be decreased. Assessed patients self- management of their health conditions. Discussed patient needs with Interdisciplinary team, educated patients, provided resources, and collaborated with providers. Resulted in decreased ER use, increased patient knowledge, improved patient outcomes, and increased ROI for BCBSM. Needed to provide safe/efficient value-based care to patients with complex medical needs and decrease risk for complications. Used InterQual to conduct chart reviews, negotiate rates, collaborate with leadership/physicians, and manage patients discharge planning. Resulted in safe delivery of value-based patient care, increased ROI, maintained satisfied patients/caregivers/families, and successfully coordinated with patients, families, faculty, and BCBSM team.PRIOR WORK HISTORYBEAUMONT HOSPITAL 05/2008 06/2014REGISTERED NURSE ADMINISTRATIVE CLINICIAN REGISTERED NURSE VISITING NURSE ASSOCIATION 09/2006 05/2008 REGISTERED NURSE CARE MANAGER HENRY FORD HOSPITAL 09/2001 09/2006 REGISTERED NURSE EDUCATIONMASTER OF SCIENCE (MS), NURSING INFORMATICS (2018) CAPELLA UNIVERSITY BACHELOR OF SCIENCE (BS), NURSING (2014) OHIO UNIVERSITY LICENSES CERTIFICATIONSREGISTERED NURSE (RN) STATE OF MICHIGANCERTIFIED CARE MANAGER (CCM) COMMISSION FOR CARE MANAGER CERTIFICATION (CCMC) BASIC LIFE SUPPORT (BLS) NATIONAL CPR FOUNDATIONMEDICAL CODING CERTIFICATION U.S. CAREER INSTITUTE FOR CODING (IN PROGRESS) AFFILIATIONSPROJECT LINUS (VOLUNTEER) GLEANERS (VOLUNTEER) NATIONAL MANAGEMENT ASSOCIATION (MEMBER) AMERICAN NURSES ASSOCIATION |
