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Click here or scroll down to respond to this candidateCandidate's Name
Cell: PHONE NUMBER AVAILABLEStreet Address
EMAIL AVAILABLEPROFESSIONAL SUMMARY:With 35 years of experience in Case Management, Utilization Review, and Case Management, this Licensed Practical Nurse (LPN) has developed extensive expertise in the field. Over a decade of experience in HEDIS and Quality Improvement/Assurance within a Managed Care setting further highlights their proficiency. They are adept in using MS Excel, Word, and Outlook. Recognized as a Subject Matter Expert (SME) for the integration of UTSW, NTSP, and THR for Utilization Management with Deloitte and Navigant, they have also served as an SME for Pivot Tables during a Six Sigma Project. They hold certifications as a Professional Utilization Manager/Reviewer and are Care Enhance InterQual Certified. Additionally, they are experienced with Cite Care Web QI Milliman Care Guidelines. Their technical proficiency extends to Acuity, CCMS, QNXT, Salesforce, Availity, NCCN, CMS, Amion, and Epicor.EDUCATION:EDUCATION:Herzing University Kenner, La 2003Diploma, Nurse Paralegal/Legal Nurse ConsultantLouisiana Technical College New Orleans, LA 1989Diploma, Practical Nursing (Collier Campus)St. Marys Academy New Orleans, LA 1984High School DiplomaSKILLS: Patient Assessment Vital Monitoring EKG Interpretation Medication Administration Patient Education Cardiac Rehabilitation IV Therapy Emergency Response Process Improvement Compliance Monitoring Risk Management Policy Development Staff Training Audit Coordination Performance EvaluationWORK EXPERIENCE:Texas Health Heart and Vascular-THPG Frisco, TX Jan 2024 - Jul 2024 LVN Lead for Cardiology (3 Clinics) Coordinate leadership and staff meetings with Business Manager and Lead Provide Develop meeting agendas and training materials. Evaluate staff at 30, 60, 90 days, and annually. Report illness or emergencies to Business Manager. Participate in various administrative committees. Monitor and report safety hazards and facility need. Train new MAs and LVNs on OHSA and infection control policies. Conduct safety walkthroughs for new employees. Ensure cleanliness and safety in work areas. Review weekly operational reports. Research, analyze, and implement procedures. Monitor patient flow for efficiency. Ensure patient-centered care. Enforce dress code and professionalism policies. Prevent staff social networking during work hours. Southwestern Health Resources, Health Plan, Farmers Branch, TX Sep 2019 to Dec 2023 Utilization Management Review Nurse First nurse cross-trained in Outpatient (Pre-Cert) and Home Health (HH)/Durable Medical Equipment (DME) teams. One of two nurses to receive perfect quality audits. Partner with physicians, social workers, pharmacists, and other professionals. Apply decision support criteria accurately. Manage complex cases proficiently. Understand funding resources, services, clinical standards, and outcomes. Adhere to case management standards (assessment, planning, interventions, evaluation). Knowledgeable in managed care trends, Medicare, Medicaid regulations, reimbursement methods. Develop interfaces with internal and external customers. Participate in multi-disciplinary team rounds and address care issues. Implement and coordinate discharge plans to prevent delays. Refer complex risk members to case management. Ensure timely and accurate documentation per guidelines. Refer cases for medical review when necessary. Make objective, fact-based decisions. Support organizational mission, policies, and procedures. Eliminate boundaries for efficient, quality service. Ensure compliance with regulatory agencies. Serve as a knowledgeable resource to employees and customers. Review and adhere to department policies and UM/Case Management requirements. Complete interdepartmental education. Utilize resources efficiently and maintain a safe environment. Participate in performance improvement activities. Coordinate with medical directors for URAC/NCQA accredited reviews. Develop documentation templates for integrated teams. Train in new documentation systems and implement new workflows. Mentor UTSW team in new documentation system. Exceed initial goals for new metrics. Maintain over 99% accuracy for QA purposes. Review service requests and recommend service levels per policies. Report on quality of care, case reviews, and operational procedures. Expertise in Utilization and Case Management. SME in InterQual, MCG, Milliman, and other methodologies. Train and develop case management and utilization review processes. Review cases for ACO and MA programs (Home Health and DME). Monitor and modify care management plans as needed. Identify high-risk members and coordinate care. Conduct assessments and develop specific care management plans. Strong organizational skills for managing communications and referrals. Participate in weekly care review meetings. Excellent written and verbal communication skills. Lead the team, act as a resource and SME. Identify and recommend methods to improve services, workflows, and processes. The University of Texas Southwestern Medical Center Dallas, TX Dec 2018 -Aug 2019 PHSC Post-Acute Utilization Specialist (PA- US) Develop documentation templates for integrated teams with management. Train in new documentation systems. Vet and implement new workflows for the home health team. Mentor UTSW team in new documentation system. Exceed initial goals and expectations for new metrics. Maintain over 99% accuracy for QA purposes. Review service requests, collect data, and recommend service levels per policies. Participate in quality of care reporting and provide information on utilization and operations. Expertise in Utilization and Case Management (assessment, processes, procedures, care plans, reimbursement principles). SME in Utilization efforts, including InterQual, MCG, Milliman, and other methodologies. Train and develop case management, utilization management, and review processes and tools. Review cases for ACO and MA programs (Home Health and DME). Monitor and evaluate care management plans and modify as needed. Identify high-risk members and coordinate care with the healthcare team. Conduct assessments and develop specific care management plans. Strong organizational skills for tracking and managing communications and referrals. Participate in weekly care review meetings. Excellent written and verbal communication skills. Lead the team, act as a resource and SME. Identify and recommend methods to improve services, workflows, and processes. WellCare Health Plans, Inc. Dallas, TX Feb 2017- Jan 2019 Quality Practice Advisor (QPA) Educate providers on NCQA HEDIS measures, medical record documentation, and appropriate coding. Resolve deficiencies to meet State and Federal HEDIS standards. Act as a HEDIS measures resource for the market. Support quality improvement interventions and audits with plan providers. Advise and educate providers on HEDIS measures, documentation guidelines, and ICD-9/10 CPT coding. Collect, summarize, and trend provider performance data for improvement strategies. Collaborate with Provider Relations to enhance provider performance in Quality, Risk Adjustment, and Operations. Train and develop case management, utilization management, and review processes and tools. Deliver provider-specific metrics and coach on gap-closing opportunities. Identify practice needs and provide support. Develop and maintain provider clinical relationships across product lines. Identify and resolve service gaps with providers. Lead/support collaborative business partnerships and make recommendations. Partner with physicians to encourage member clinical participation in wellness and education. Provide resources and educational opportunities, capturing concerns and issues in action plans. Healthcare Support Staffing Dallas, TX Nov 2016- Jan 2017 WellCare Health Plans, Inc. Quality Practice Advisor (QPA) Establish and foster relationships between large physician practices, IPAs, and WellCare. Educate providers on NCQA HEDIS measures, medical record documentation, and appropriate coding. Resolve deficiencies to meet State and Federal HEDIS standards. Act as a HEDIS measures resource for the market. Support quality improvement interventions and audits with plan providers. Advise and educate providers on HEDIS measures, documentation guidelines, and ICD-9/10 CPT coding. Collect, summarize, and trend provider performance data for improvement strategies. Collaborate with Provider Relations to enhance provider performance in Quality, Risk Adjustment, and Operations. Train and develop case management, utilization management, and review processes and tools. Deliver provider-specific metrics and coach on gap-closing opportunities. Identify practice needs and provide support. Develop and maintain provider clinical relationships across product lines. Identify and resolve service gaps with providers. Lead/support collaborative business partnerships and make recommendations. Partner with physicians to encourage member clinical participation in wellness and education. Provide resources and educational opportunities, capturing concerns and issues in action plans. Document action plans, visit details, outcomes, and report critical incidents and quality of care issues. Communicate with external data sources for necessary outcome measurements. Provide communication through newsletters, member education, outreach interventions, and provider education. Support quality improvement HEDIS and program studies, maintain databases, and research provider encounter history. Ensure compliance of documentation with state regulations and accrediting body requirements. Ensure accuracy of contract/regulatory reports and adherence to deadlines. Represent the plan at community, health department, and organizational meetings on quality improvement and member education. Ensure accuracy in medical records for data collection, data entry, and reporting. Enter findings in identified databases.CIGNA- HealthSpring (Managed Care) Dallas, TX Oct 2015 Aug 2016 LPN Health Services Senior Specialist Medicaid (Outpatient Utilization Manager) Manage HEDIS implementation and compliance. Ensure quality review and assurance for denial processes related to CMS remediation. Conduct ODAG reports and testing for CMS remediation. Lead Operation Effectiveness Pilot Rollout and Integration. Identify, plan, coordinate, and implement corporate Quality Improvement initiatives. Develop data collection methodology for NCQA/CMS-related QI projects. Track project progress and report to Quality Improvement lead and CQIC. Develop compliant departmental policies for NCQA and CMS. Supervise assigned staff directly. Train and develop case management, utilization management, and review processes. Review and provide recommendations on work performed by others. Analyze department statistics routinely. Utilize CCMS, InterQual, QNXT, and CERME effectively. Act as liaison for TMF/TDI issues in North Texas office. Manage internal communications for project activities and outcomes. Support CCIP and QIP annual CMS submission process. Assist in developing Job Aids for the department. Motivate team members. Understand and resolve customer needs and issues proactively. Serve as key resource on complex issues. Solve complex problems and innovate solutions. Develop workflows and SOPs. Assist with initial and ongoing training needs. Monitor staff caseloads. Conduct routine audits and evaluate staff performance. CIGNA- HealthSpring (Managed Care) Dallas, TX Aug 2013 Jul 2015 LPN Medical Claims Review Senior Associate Medicare Expertise in HEDIS implementation and compliance. Conduct quality review and assurance for denial processes. Proficient in CCMS, InterQual, QNXT, and CERME systems. Manage Quality Review and Assurance for outpatient, RPO, and commercial sectors (12/01/14 - current). Manage TX UM Denial Inbox for inpatient, outpatient, and commercial cases (04/2014 - 10/01/2014). Assisted in managing TX UM Denial Inbox until 07/2013 - 04/2014. Resolve Medicare issues according to Kepro/TMF (QIO)/TDI guidelines. Manage Medicare appeals. Oversee Grijalva (Inpatient and Outpatient) cases to resolution. Act as liaison for TMF/TDI issues in North Texas office. CIGNA- HealthSpring (Managed Care) Dallas, TX Apr 2011 Jul 2013 Inpatient Review Nurse 1, Case Coordinator Medicare Manage Case Management and Utilization Review for MAP plans (HealthSpring and Bravo) with HEDIS measures. Proficient in CCMS, InterQual, QNXT, and CERME systems. Organize and manage POD Meetings for THPG. Oversee management of over 60 patients daily. Train NTX IRN Staff for efficiency in their roles. Global Rehab Hospital, Dallas, TX 2010 - 2011Lead Case Manager Manage Case Management and Utilization Review for LTAC (ICU and ICU step-down) unit. Attend and participate in Quality Improvement Committee and Medical Executive Board meetings. Oversee an average daily census of 30-35 patients. Manage an average discharge cost of approximately $10,000 per patient. Responsible for day-to-day unit management. Oversee evaluation and admission of all patients. Manage day-to-day Risk Management of patient activities and records. Assist in ensuring daily Patient/Family Satisfaction. Act as a liaison between Physicians, Nurses, Patients, Families, and the Host Community. Serve as Administrator on Call within Management Rotation. Epic Home Health Dallas, TX 2006 2013LVN, Pediatric Trach /Vent Certified Nurse (Per Diem) Select Specialty Hospital, Scottsdale, AZ / Gulfport, MS / South Dallas, TX 2005- 2008 Lead/Certified Nurse Case Manager Manage Case Management and Utilization Review for LTAC (ICU and ICU step-down) unit. Attend and participate in Quality Improvement Committee and Medical Executive Board meetings. Oversee an average daily census of 70 patients. Manage an average discharge cost of approximately $15,000 per patient. Responsible for day-to-day unit management. Oversee evaluation and admission of all patients. Manage day-to-day Risk Management of patient activities and records. Assist in ensuring daily Patient/Family Satisfaction. Act as a liaison between Physicians, Nurses, Patients, Families, and the Host Community. Serve as Administrator on Call within Management Rotation. OTHER LPN EXPERIENCE:LPN Case Manager at West Jefferson Medical Center, Marrero, LA 2005 Director of Case Management and Utilization Review at Bywater Hospital, New Orleans, LA 2003 2005 Assistant Director of Risk Management and Compliance at Bywater Hospital, New Orleans, LA 2004-2005 LPN Utilization Review at Select Hospital, New Orleans, LA 2003 2005 Contract LPN at Advantage Nursing Services 1990 2005 Behavioral Health/Psychiatric Step Down Emergency Room Same Day Surgery Pediatrics/Infants and ToddlersLPN Charge Nurse at LSU Health Sciences Center, New Orleans, LA 2002 2005 LPN Clinical Manager at East Jefferson General Hospital, Kenner, LA 2001 2002 Staff LPN at Tulane University Hospital and Clinics, New Orleans, LA 1997 2001 Clinical Research Nurse @ Clinical Research Center of New Orleans, LA 1995-1997 |
