Clinical Programs Director Resume Example

Managed team of 11 UM nurses and 4 social worker/discharge planners

-Worked with Finance team on large case accounts to address appropriate and timely medical care as well as discharge plans

-Attended JOCs (Joint Operation Collaboration) with local facilities as needed to maintain healthy communication and collaboration between our Utilization Management and Case Management teams

-Involved in multiple plan projects including: Hospitalist Integration; BH-PH Integration; URTI Project Improvement Program; UM-CM Referral Collaboration and more.

-Met all TDI and NCQA requirements annually

-Lead our UM team to exceed PIE audits and PAV report

-Worked with other departments to maintain accountability for the members we serve

-Initiative owner for Patient Navigator where members at high risk for readmission were identified while still inpatient and onsite visits were scheduled to meet with these members at the bedside to help identify reason for frequent readmissions and to work with member and hospital staff to address those issues and prevent future readmissions. This initiative exceeded the projected cost savings by 100,000.00.

*Provided case management services for our high risk Star Plus Medicaid members

*Maintained optimal or higher case loads while maintaining all operational procedures, guidelines and NCQA requirements

*Provided onsite utilization reviews for members at local hospitals including Children's Medical Center for our pediatric members

*Provided onsite utilization reviews for our NICU members at HCA and THR facilities in Arlington, TX

*Provided telephonic/fax utilization review for statewide facilities

*Collaborated with social workers and NICU medical director consultant for program: You and Your Baby in the NICU

-Coordinated onsite visits to high risk NICU members were made while their mother's were still inpatient post delivery or while they were visiting their babies in the NICU.

-During our visits, mother's were provided education about what was happening with their babies in the NICU and they were encouraged to have active participation in their babies care when appropriate.

-Created a pamphlet outlining health plan resources and phone numbers.

*Provided training to our UM team during a statewide roll out of membership.

-Created first UM department training manual

-Web Strat SME to assist staff

-Created multi-disciplinary mock IRRs to assist staff with learning how to appropriately use InterQual guidelines while encouraging use of nursing judgement based on their clinical experience