Clinical leader in the health care industry with a unique perspective of both hospital utilization-case management as well as managed care for Medicaid, Medicare and Commercial members. Successfully implemented programs in Amerigroup, Texas that saved tax payers over 400,000.00 in just one year. In addition, implemented Anthem Enterprise wide initiatives with even greater medical cost savings.
* Planned and executed multi-million dollar Enterprise wide initiative to improve quality of care for members receiving medical care while reducing medical cost waste.
-Worked with team of other clinical program directors, project managers, actuaries and medical director leaders to create project plan for Per Diem Pillar initiative to reduce bed day costs through more appropriate management of extended inpatient stays
- Created power point presentation for this initiative to share with upper executive leadership
-Implemented training for multi-market health plan staff to support Enterprise wide initiatives for managing medical costs while providing high quality health care.
- Created job aids and resource tools to assist health plans with implementing the initiative successfully
-Collaborated with health plans to align their teams within existing resources and talent to ensure successful implementation of these initiatives.
- Worked closely with actuaries to monitor and report to each market and health plan ongoing success with progress in the initiative
-Worked with Regional RVP to create new medical director onboarding and training program
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
May 1999-December 2006: ACS-Texas Medicaid and Health Care Partnership-Primary Care Case Management Program-Dallas, Texas
January 1990-May 1999: Children's Medical Center of Dallas-Dallas, Texas
January 1985-February 1990: Charlton Methodist Hospital-Dallas, Texas
August 1982-September 1984: Texas Scottish Rite Hospital-Dallas, Texas
September 1981-August 1982: Charlton Methodist Hospital-Dallas, Texas
January 1980-June 1981: Texas Children's Hospital-Houston, Texas
Current Texas Nurse Licensure
Current Certified Case Manager
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