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Click here or scroll down to respond to this candidateCandidate's Name
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EMAIL AVAILABLE / PHONE NUMBER AVAILABLESUMMARY OF PROFESSIONAL EXPERIENCEMedical Cost Management, Inc. (MCM)Director of Case Management (CM) and Disease Management (DM) Apr 2010 to Jul 2020Responsible for management of RN nursing and care coordinator staff providing telephonic medical review and treatment plan implementation for patients suffering high-risk and chronic conditions for over 250 clients with approximately 300,000 covered lives.Designed and implemented specialty case management for Oncology, Transplant, and high risk Maternal/Child cases.Conducted medical review of high dollar or questionable claims with recommended pricing when applicable.Implemented chronic condition management services for Asthma, COPD, Coronary disease and Diabetes utilizing predictive modeling analysis to identify high risk patients, coaching patients to better health and measure improvement.Implemented medical review of sub-acute services for medical and mental health related conditions.Provided staff development regarding coordination of care, 3-point contact (patient/family, providers, and payors) and documentation of interventions.Performed management duties including budget, productivity metrics, recruitment/retention, staff development, HIPPA compliance. Key presenter at client and prospective client meetings.VP Clinical Operations Jul 2020 to Feb 2023Responsible for nursing staff and intake staff supporting UM, CM and DM programs.Designed and implemented integration plan for re-assignment of staffing to equalize caseloads and responsibilities.Provided staff development on policies, procedures, workflows, productivity metrics, documentation of interventions and client service.Performed management duties including budget, productivity metrics, recruitment/retention, staff development, HIPPA compliance and URAC accreditation. Key presenter at client meetings.Performed case management for high profile cases and cross coverage when staffing levels were down.HealthSmart, National Director of CM and DM Dec 2005 to Apr 2010Directed telephonic case management and disease management programs based on URAC standards for 60 TPA clients comprising 646 employer groups ranging in size from 250 to 10,000 covered lives.Implemented large claim management for Oncology, Transplant, high risk Maternal/Child and multi-trauma cases with ROI $5.23 to $1 and reduced preterm delivery rate by 75%.Implemented chronic condition management services for Asthma, CAD, COPD and Diabetes utilizing predictive modeling analysis to identify high risk patients, coaching patients to better health and measure improvement.Implemented medical review of sub-acute services for medical and mental health related conditions.Provided staff development regarding coordination of care, 3-point contact (patient/family, providers and payors) and documentation of interventions.Performed management duties including budget, productivity metrics, recruitment/retention, staff development, HIPPA compliance. Key presenter at client meetings.Candidate's Name Resume Page 2JOB HISTORY PRIOR TO 2005Concentra as Field Case Manager Apr 2004 to Dec 2005Fremont Comp Insurance as Director CM for Workers Comp Oct 1996 to Jul 2003Blue Cross HMO as Regional Manager Jul 1995 to Sep 1996DePaul University as Executive Assistant to President Apr 1993 to Jul 1995Resource System Solutions as Health Care Consultant Sept 1991 to Apr 1993DePaul Health Center as Director of Quality/Patient Care Services Apr 1988 to Aug 1991General American Insurance as Manager Cost Containment Sept 1985 to Apr 1988Medicare PRO as Cost Outlier Auditor Mar 1984 to Jun 1985Barnes-Jewish Health Center as ICU Nurse Sept 1976 to Mar 1984EDUCATIONAL BACKGROUND & CERTIFICATIONSMaster of Science, Health Administration, DePaul University, Chicago ILBachelor of Arts, Sociology and Nursing, Maryville University, St. Louis MORegistered Nurse, Illinois License ActiveCase Management (CCM) certification |
