Case Manager Resume Example MEDVAMC

CASE MANAGER

Professional Summary

Experienced Certified Case Manager providing a committment to quality care and collaboration to promote a positive transition throughout the continuum of care for all patients .

Licenses

State of Texas RN # 610192( expires 8/16)

Certified Case Manager since 1994

Professional Experience

MEDVAMCDecember 2013 to CurrentCase Manager
Houston, TX

Assisted with development of the newly created Case Management services.
Formed morning meetings with the vascular medical team to discuss pt. care and progress and discharge planning needs and barriers
Developed with the vascular physicians, and other medical team members, to focus on the effeceint use of resources through the continuum of care
Educated physicians and staff

The Methodist HospitalFebruary 2001 to December 2013Case Manager
Houston, TX

Assessment of all patients to begin discharge preparation at the beginning of their.
hospital stay Participates in interdisciplinary rounds to be sure the patient is moving through the continuum of care and to prepare for an effective discharge plan.
Educating staff on discharge planning procedures in coordinating post hospital care.
Physician education of proper levels of care as they pertain to interqual criteria and Medicare guidelines.
Perform concurrent reviews on each patient for level of care appropriateness and for insurance review.
Participate in long length of stay meetings to discuss barriers to discharge with our physician advisor, management team to develop new opportunities in order to assist with getting the pt.
onto the next level of care.
Perform utilization review to insure proper level of care and criteria.
Provide community resources when needed.
Participated on various committees.

UTMB Healthcare SystemsMarch 1999 to February 2001Case Manager
Galveston, Texas

Performed assessments of patients medical needs to ensure movement throughout the continuum of care while an in patient.
Assessed the patient for medical necessity and for appropriate level of care as per medicare guidelines and interqual criteria.
Provided discharge planning for home health, snf ,rehab, or ltacs based on the pt's needs.
Worked with the medical teams to coordinate pt's needs and educating them on levels of care and discharge options.

AmeriHealth Texas, IncMay 1997 to March 1999Case Manager
Houston, TX.

Assisted with the start up operations of this affiliate of BCBS that covered HMO, PPO, and Medicaid replacement products.
Participated in the state meetings with the Texas Dept.
of Health to learn their expectations of the STAR Health plans.
Identified ancillary providers that would be servicing our members and negotiated fee structures.
Trained new personnel and acted as an ongoing resource for all departments of the company.
Participated on the corporate policy and procedure committee to adjust current policies to meet the needs of the local office.
Performed concurrent reviews for in and out of area, snf and rehab members for all disease processes.
Coordinated transitions of care for new members into the network.
Worked with the delegated IPAs to be sure members needs were met and performed audits, as required, on utilization management functions.

Cigna HealthcareSeptember 1996 to May 1997Case Manager
Houston, TX

Performed disease case management for members with chronic diseases, i.e.
HIV/AIDs, transplants, and musculoskeletal problems.
Assisted with identification and coordination of care for hi-risk OB members.
Worked closely with self-funded employer groups concerning catastrophic cases.
Coordinated care of members transitioning into the health plan.

MacGregor Medical AssociationJanuary 1995 to September 1996Supervisor Sr. Care Case
Houston, TX.

Developed the Senior Care Case Management Dept.
at MMA that provided care for the Prudential SeniorCare Medicare risk product.
Created a team of professionals that worked toward the goal of the optimal management of the Senior Care member.
This team included a medical director, 2 nurse practitioners, 2 assistants, a Social worker, 2 case managers, and myself.
Participated in the development of Educational Forums for disease specific categories such as CHF and provided the members with a CHF diary.
Also, worked with the Home Health Agencies that had abilities to provide care and continued follow up at home through some of the Medicare projects such as for the CHF patients with Cardiac Solutions.
Worked closely with the capitated ancillary provider for home health, Olsten, to assure quality care of the members and to act as a liaison between the provider, the medical group, and the insurance company.
Participated in the preparation for the NCQA review.
Responded to HCFA concerning member issues.

Home Health ExperiencesNovember 1992 to December 1994Case Manager
Philadelphia, PA

Provided telephonic review for all types of patients in a variety of settings i.e., hospitals, SNFs, Rehabs, and home hospice.
Managed the HIV/AIDS and pt on hospice and worked on developing policies and procedures for both of these categories.
Worked in conjunction with Independence Blue Cross case managers and medical directors in the development of the HIV/AIDS program that would be instituted for all the products of the Family of Blues.
Assisted with difficult discharge planning and placements negotiating individualized services as appropriate for the member.

Community Health AffiliatesNovember 1992 to December 1994weekend staff RN
Ardmore, PA

Northwest Florida Home HealthFebruary 1992 to August 1992Staff RN
Pensacola, FL.

Riverside Medical CenterJuly 1991 to January 1992Staff RN
Franklinton, LA

Seventh Ward General HospitalSeptember 1989 to January 1992staff RN
Hammond, LA

Seventh Ward General HospitalSeptember 1989 to January 1992Float pool RN
Hammond, LA

Ochsner Foundation HospitalMay 1988 to August 1989Staff RN
New Orleans, LA

St. Tammany Parish HospitalJanuary 1988 to May 1988Staff RN
Covington, LA

Functioned as a staff nurse in ICU, Orthopedics, Telemetry, SNF and Med/Surg and Charge nurse functions when required.
Performed all manor of Respiratory Therapies while working as a Respiratory Technician prior to becoming a registered nurse.

Education and Training

Southeastern LA University12/1987Bachelor of Science: NursingHammond, LA

Professional Affiliations

Case Management Society of America-1995-2004

Board Member at Large -- 1996-1997)

Texas Gulf Coast Association for Healthcare Quality -1996

Participate in annual CMSA and ACMA conferences.

Skills

Case Management, discharge planning, Home Health, hospice, insurance, negotiating networks, developing policies, processes, quality, Senior Care.

Resume Overview

Companies Worked For:

MEDVAMC
The Methodist Hospital
UTMB Healthcare Systems
AmeriHealth Texas, Inc
Cigna Healthcare
MacGregor Medical Association
Home Health Experiences
Community Health Affiliates
Northwest Florida Home Health
Riverside Medical Center
Seventh Ward General Hospital
Ochsner Foundation Hospital
St. Tammany Parish Hospital

School Attended

Southeastern LA University

Job Titles Held:

Case Manager
Supervisor Sr. Care Case
weekend staff RN
Staff RN
staff RN
Float pool RN

Degrees

Bachelor of Science : Nursing

Case Manager Resume Example

Resume Score: 90%

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