To help implement and provide exemplary case management, through utilization review, care coordination, and appropriate timely discharge planning expertise while maintaining the company's identity with the vision to be entrusted as the best institution to give compassionate and best quality patient care in the health care industry. Professional Experience/Expertise/Achievements: Hospital Case Manager/Care Coordinator/Discharge Planner Attends Corporate Division teleconference discussion on payer denial cases after researching for the root cause and analysis and provides resolution to improve and prevent more denials in the future. Assures the appropriate application of internal and external utilization review for hospital patients. Assess medical necessity for patient admission and appropriate level of care. Interacts with payers to assure timely and accurate communication of patient status and plans of care, identifying alternate options with payers for individual patients. Monitors 2 Midnight Rule forms for Medicare patients are appropriately signed by attending physicians in timely manner and before patient is discharged. Assigns appropriate DRG Codes on all patient chart review regardless of payer source. Proactive in coordinating the plan of care on patients' appropriate discharge plan disposition to the next level of care through good communication with doctors, patient and family, Social Worker, nurses, and therapy staff. Provides assistance to Social Worker in facilitating referrals to the next appropriate level of care thus advocating the use of patient's benefits and reducing the length of stay. Prepares weekly reports for resource meeting on difficult discharge planning, patients with longer stay than the allowable average length of stay per DRG, as well as readmissions. Monitors and enters data for tracking patients' readmissions, avoidable days and interventions with payers on approved or denied hospital days. Facilitates Medical Peer to Peer review as needed for insurance denied cases. CM Cardio-Thoracic QA Facilitator: Reviews charts for QA issues peri-op, intra-op and post- op and prepares synopsis for the monthly Cardio-Thoracic QA meetings with the cardio thoracic surgeons. Clinical Documentation Improvement Nurse Daily review of patients' records to make sure that appropriate documentation is being provided by physicians. Concurrent query to physicians for ambiguous documentation, specificity of diagnosis, acuity and etiology of certain conditions Education provided to physicians for documentation improvement based on the severity of illness and the risk of mortality. Admissions Coordinator /Liaison Assesses and evaluates hospital referrals of patients for appropriate admission to a long term acute care facility (LTAC). Insurance Case Manager Reviews patients' clinical information received from the providers and makes decision for approval or denial of services requested, whether it is a patient hospital stay, outpatient procedures, tests, homecare, rehab, and hospice services as well as long term acute care and skilled nursing facility services. Drafts for the contract on negotiated rates for out of network providers and services not covered by patients' insurance benefits. Provides denial letters to facilities, providers, and patients if services requested are not deemed appropriate by the insurance. Administrative Nursing Supervisor Supervision of more than 25 employees in acute long term care facility as well as inpatient acute rehab facility. Provided staff assistance in taking care of medically complex patients on vents, dialysis, post heart and lung transplants/open heart bypass, orthopedic and neuron. Facilitated patient/family/staff conference, staff schedule and employee evaluations. Clinical Nurse Worked as ER Nurse/ICU/CCU Nurse, and Cardio-Thoracic Telemetry nurse. Took care of vent/trached patients, post op telemetry cardio-thoracic surgeries such as heart and lung transplants, heart bypass and thoracotomies.
Case Manager, 10/2011 to CurrentMedical Center of McKinney － McKinney, Texas
Case Manager, 08/2010 to 10/2011Medical Center of Plano － Plano, Texas