Allscripts Care Management
Total Health CareDetroit, MIQuality Improvement Director12/2015 to Current
Responsibilities include but are not limited to completion of Michigan Department of Health and Human Services (MDHHS) Medicaid contract compliance deliverables including pay for performance projects.
Project manager for the annual HEDIS administrative and medical record review project for Medicaid, Commercial and Marketplace product lines.
Responsible for the NCQA accreditation process and survey submission for Medicaid, Commercial and Marketplace product lines.
Project Manager for the annual Adult and Child CAHPS for Medicaid and Commercial products and QHP project for the Marketplace product.
Responsible for the annual submission of the Quality Improvement Strategy for the Qualified Health Plan (Marketplace) line of business.
Creation and oversight of the multi-year population health management and health equity plan.
Collaboration with community partners for high touch case management.
Collaboration with community mental health authorities and pre-paid inpatient health plans in Wayne, Macomb and Oakland counties for joint case management of members with mild to moderate mental illness as well as members who are severely and persistently mentally ill.
Achieved NCQA accreditation for all three lines of business in June of 2016.
THC realized an overall improvement of HEDIS and CAHPS rates during the two seasons I managed the projects.
Collaborated with Health Michigan Dental (Dencap) to create a care integration program to increase utilization of dental benefits and coordinate care for Healthy Michigan Plan members who are seen in the emergency department for dental related diagnoses.
DMC-VANGUARD-TENETDetroit, MIRegional Director07/2013 to 12/2013
Ensured cost effective and quality patient care through the appropriate utilization of hospital resources.
Acted as a resource to the medical staff, administrative staff, and external regulatory agencies in all issues relating to utilization management.
Analyzed and reported significant utilization trends, patterns, and impact to appropriate departmental and medical staff committees.
Ensured compliance with federal and state regulations, JCAHO and other regulatory agencies, and internal standards and requirements.
Facilitated educational training for medical staff on issues related to utilization management.
Ensured that staff assignments were covered each day for all sites.
Served as a point person for surgical boarding/procedural authorization issues.
Ensured that processes and workflows were followed to maximize efficiency.
Ensured consistency and quality of reviews.
Acted as system administrator for Allscripts Care Management product.
DMC-TENET HARPER/HUTZEL/CVIDetroit, MIDirector of Case04/2013 to 11/2015
Director of Case Management for a 380 bed tertiary care center that provides sub-specialty care to patients from across the country and around the world.
Clinical services include but are not limited to: obstetrics and gynecology, perinatology, neonatology, neuroscience, cardiology and bariatric surgery.
Department is comprised of a Nurse Manager of Case Management, 22 RN Case Managers, 11 Social Workers, 4 Care Management Technicians and 1 Administrative Assistant.
The department is focused on decreasing the length of the acute inpatient hospital stay and readmission risk through the delivery of top notch transitional assessments and planning.
Reduced excess days by 7% using a multidisciplinary collaborative approach and visual controls.
Reduced the readmission rate from 21% to 14.9% by focusing on transitional assessments on high risk patients and improving transitional care coordination by partnering with community agencies to increase resources for patients with chronic diseases and other socio-economic issues.
Improved staff retention by decompressing the salary range for Case Management RNs and SWs to bring salaries up to the competitive market rate
Overall responsibility for hospital utilization performance improvement and operational management of the Case Management Department.
Promoted effective utilization of hospital resources, ensured processes support appropriate reimbursement for services rendered, supported efficient patient throughput and ensured compliance with all state and federal regulations related to case management services.
Integrated national standards for case management scope of services including utilization management supporting medical necessity and denial prevention, transition management promoting appropriate length of stay, readmission prevention and patient satisfaction, care coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care, compliance with state and federal regulatory requirements, accreditation standards and Tenet policy, education provided to physicians, patients, families and caregivers.
Managed department operations, lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement, ensured medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet Policy, ensured timely and effective patient transition and planning to support efficient patient throughput and implemented and monitored processes to prevent payer disputes.
DMC-TENETDetroit, MIInterim Vice President12/2012 to 04/2013
Lead the company strategy and execution for Case Management, including the clinical and financial operations.
Collaborated with numerous executive stakeholders including Operations, Ethics & Compliance, Audit, Legal, and Regulations.
Worked directly with Group CFOs, Division CFOs, and Division Directors of Case Management to support all aspects of Case Management.
Sought guidance from internal and external resources as needed to develop and execute the Case Management strategy and delivery model.
Established and lead dedicated teams that provided specialized support in key focus areas including Care Coordination, Discharge Planning, Utilization Review, Education, Finance, Technology, and Analytics.
In conjunction with Regulations and Legal, held responsibility for setting the operational strategy for Case Management policies and processes in accordance with regulatory and compliance requirements.
This included defining the strategy, implementation, monitoring, and division/facility support.
Prepared budgets and business plans, monthly reporting and results, managed CM related costs including technology fees for systems and clinical criteria.
Possessed strategic vision, excellent communication skills, proven motivational capabilities, an executive presence, and developed a demonstrated track record of delivering results and achieving goals.
DMC HURON VALLEY SINAI-HOSPITALCommerce, MIManager09/2012 to 07/2013
Provided management and operational oversight for the care management, social work and discharge planning at Huron Valley Sinai Hospital.
Managed day to day operations of the department to ensure hospital objectives are accomplished.
Monitored the quality and productivity of staff.
Approved personnel actions, completed performance appraisals and ensured competency of staff.
Ensured consistent and coordinated delivery of all assigned processes within the hospital.
Assisted in the development of daily, monthly and/or yearly goals and measures for the department as well as assessment of goal attainment.
Developed and implemented education and orientation programs for personnel.
Assisted in developing and monitoring the budget.
Identified the need for and drafted or defined procedures and protocols in collaboration with higher management input.
Maintained accountability for third party payer communications for utilization review and discharge planning and decision making.
Monitored activities for and ensured compliance with laws, third party payer requirements, government regulations and Joint Commission requirements pertaining to areas of responsibility.
As directed, implemented external and internal audit recommendations.
Engaged physician advisor to facilitate care decisions, as needed.
Established and maintained effective relationships with physicians and all other staff members.
Maintained a working knowledge of the requirements of payers, regulatory and compliance entities.
Exhibited behavioral skills that promote a positive customer relations environment.
Worked to resolve customer dissatisfaction to a high degree of service excellence.
Superuser for Allscripts Care Management product.
Assisted in implementation of Adreima 2nd level review process.
DMC HURON VALLEY SINAI HOSPITALCommerce, MILead Case Management Specialist10/2011 to 09/2012
Provided management and leadership for the Case Management/Discharge Planning and Access Management processes at Huron Valley Sinai Hospital.
Developed and implemented education and orientation programs for personnel.
Monitored and ensured compliance with all regulatory and agency requirements.
Identified the need for and defined procedures in collaboration with corporate input, goals and objectives; modified procedures as needed.
Monitored the quality of workflow to ensure work is completed.
Developed and measured goals for the department.
Maintained accountability for patient coverage.
Maintained accountability for third party payer communications.
Implemented external and internal audit recommendations.
Ensured hospital departments achieve objectives for diversity of resource providers in the community.
DMC-HURON VALLEY SINAI HOSPITALCommerce, MICase Management Specialist07/2011 to 10/2011
Provided hospital case management/utilization review and discharge planning to assure that the patient progresses through the continuum of care.
Coordinated the hospital activities concerned with case management and discharge planning.
Adhered to departmental goals, objectives, standards of performance, and policies and procedures.
Ensured compliance with quality patient care and regulatory compliance.
DMC-HURON VALLEY SINAI HOSPITALCommerce, MIAccess Management Specialist03/2007 to 07/2011
Managed critical care and progressive care, as well as general medical/surgical bed placements from the emergency and surgery departments.
Facilitated placement of direct admissions and transfers from other patient care settings for physicians.
Reviewed inpatient and observation admissions from the emergency room using InterQual criteria.
Counseled physicians on appropriate placement of patients in the hospital to maintain appropriate cost, case and desired patient outcomes.
Utilized Allscripts Care Management software for admission reviews.
Utilized Teletracking XT software for patient bed placements and transfers.
Communicated with third party payers for notification and authorization of observation and inpatient admissions.
BEAUMONT HOSPITALRoyal Oak, MICare Coordinator09/2004 to 03/2007
Managed critical care beds.
Facilitated direct admissions and transfers of patients for physicians.
Reviewed inpatient admissions from the emergency room using InterQual criteria and Maxsys software.
Performed concurrent reviews on an intermediate medical and medical/surgical units.
Planned discharges for patients using community resources.
BEAUMONT HOSPITALRoyal Oak, MIRegistered Nurse/Charge Nurse11/2001 to 09/2004
Provided basic and intensive nursing care to pediatric patients in a hospital setting, as well as the pediatric sub-specialty clinic.
Worked closely with patients and their families offering emotional support.
Clinical experience in administering chemotherapy, blood products, post-surgical care and extensive diabetic education.
Gained experience in use of clinical pathways regarding patient care, teaching and clinical outcomes.
Assumed charge nurse duties.
ROBERT ROMANSouthfield, MD MIRegistered Nurse02/1999 to 02/2000
Provided nursing care to pediatric patients in an office setting.
Responsibilities included phone triage; follow-up care with patients, basic nursing care for sick and well visits.
OAKWOOD HOSPITALDearborn, MIRegistered Nurse07/1995 to 11/1998
Provided nursing care to patients in a critical care setting.
Worked closely with patients and their loved ones offering emotional support and educating them on the issues at hand.
Clinical experience in recognition and interpretation of arrhythmias, artificial ventilation, and hemodynamic monitoring.
Assumed charge nurse duties.
UNIVERSITY OF MICHIGAN MOTT HOSPITALAnn Arbor, MIStudent Nurse08/1994 to 04/1995
Provided nursing care to patients in the Hematology, Oncology and Bone Marrow Transplant Unit.
Member of interdisciplinary health care team.
Gained experience in assessment charting and S.O.A.P.
Interact extensively with families regarding the children's care, offering support and education.
Education and Training
Bachelor of Science:NursingApril, 1995EASTERN MICHIGAN UNIVERSITY, Ypsilanti, MINursing