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Jessica
Claire
resumesample@example.com
(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
:
Professional Summary
Driven and efficient registered nurse director with over 18 years utilization management, disease management, revenue cycle, appellate leadership experience.
 
Responsible direct and indirect reports ranging from local to national oversight ranging from 1-50 multidisciplinary team members including utilization management nurse/ therapists reviewers.
 
Directed all aspects of utilization management, care coordination, utilization compliance, authorizations and referrals, and discharge planning throughout various industry settings.  
 
Facilitated all levels of staff functioned within timeliness and appropriateness of case reviews and directed  team efforts to optimize appropriate length of stays, quality care/ disease management and discharage planning; both remotely and on site during audits, utilization rounds for timely, appropriate medical treatment. Taught all  levels of clinical staff to evaluate plans of care, care coordination/ administration of medical treatment documentation per payer, state, federal guidelines.
 
Directed the supervision of  daily operations of the utilization management (UM) departments, multidisciplinary staff, ensure appropriate usage of resources in order to facilitate the UM processes while within compliance of applicable state program guidelines, policies and procedures and analyze/recommend enhancements. Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements.
Lead teams to perform analysis for process improvement areas that were identified and corrective plans of action necessary to facilitate department functions changes/ corrections.
 
Educate all levels to ensure consistent performance and adhere to standards, senior direct reports with findings, corrective action plans and assist with and facilitating system processes for implementation. Directed coordination with providers, partners, vendors, and subcontractors as necessary.
Education and Training
, Expected in 2017 AAPC, CPC, CPB Anticipated completion : - GPA :
, Expected in 2013 : I-10 Bootcamp - GPA :
, Expected in 2004 Masters, Business Administration, Dowling College, : - GPA :
Hofstra University , Expected in 2006 Legal Nurse Consultant Certification : - GPA :
Nursing Adelphi University , Expected in 1991 Bachelors : - GPA :
Professional Experience
EMR Compliance, Audits And Consultants, LLC - Utilization Management Healthcare Consultant
City, STATE, 01/2014 - Current

  • Established, directed and grew national corporate Utilization Regulatory Department to oversee: National Managed care insurance organizations with on-site and remote audits, prepare and respond to surveys, denials/ appeals and revenue/ claims management, clinical documentation and utilization/ disease management oversight for supporting 22 states. Including, but not limited to: CMS, OIG, CIA, State and Federal audits. 
  • Project Management: Health Information Technology Specialists: EMR implementation workflow analysis, Go -Live delivery for the following platforms: McKesson Horizon, Cerner, DeVero, Allscripts, Homecare Homebase, Allscripts, AMS2, HAS.
  • Lead a $50M Medicare Corporate Integrity Agreement- OIG Project resulting in a cost savings of 37% 5:5 years of agreement, minimized recoupment efforts via successful collaboration with Ernst and Young through internal audit securing appropriate utilzation, scope of care, disese management and revenues (codes/ treatment plans, care plan oversight) were within parameters set forth by governing bodies appropriately. Managed the revenue recoupment audits and appeals process surrounding them. 
  • High level national oversight of HIM practices during transition to EMR platform and participated in think tank for same corporation.
Skill/ Experiences:
Utilization Project Management: Disease Managment, Utilization Management, Regulatory, Compliance Audit Projects for Federal/State/Commercial Payers, Third Party Liability Project: lead department medical record reviews to identify potential/ actual compliance risks, coverage issues , coding/ treatment plan delivery of care systems and reduced a $622K fiscal exposure by 40% ($250K) for the State of Massachusetts, 37% ($2.3M) reduction, $6.3M reduction for Connecticut Third Party Liability Project.
 
Direct reports
: 8-50 regionally, locally, nationally. Directed all level clinical teams with Utilization Reviews, Case Management, Federal and State Regulations, Medicare, and Managed Care audits/ medical records.
 
Computer Proficient; Windows, EMR, McKesson Horizon, Cerner, DeVero, Allscripts, Homecare Homebase, Allscripts, AMS2, HAS, taught nationally all these platforms to various healthcare teams nationally. 
 
Accomplishments: Leadership, Healthcare Operations Consultant: Effective in identifying efficiencies involving: work flow analysis, reimbursement processes and team engagement Solution/Results Oriented: Lead a $50M Medicare Corporate Integrity Agreement- OIG Project resulting in a cost savings of 37% 5:5 years of agreement.
 
Operational/Business Development: Turnaround Strategy Leadership: Business Consultant providing analysis, implementing strategies providing for optimization on all fronts. Successful growth, P&L and operational steadiness resulted in: Quarter over quarter growth meeting/exceeding established 85% admission rate threshold, effective relationship building between sales staff and operations staff (all levels) by implementing turnaround business strategies for $24M regional healthcare company (NY, OH, CT). 
 
Interests
American Association Professional Coders, AAPC 2013-present
Qualifications
Go -Live, billing, Business Administration, Business Development, business strategies, Case Management, CMS, Consultant, consultation, consulting, clients, excellent customer service, delivery, DOH, Documentation, Health Information Technology, Home Care, Homecare, Hospice, ICD-10, Insurance, internal audit, Leadership, law, Legal, market strategies, Marketing, Policy analysis, process management, Project Management, Regulatory Affairs, Sales, surveys, venture capital, workflow analysis
Additional Information
  • Licenses/Professional Affiliations: FL State Health/ Life Insurance Agent FL215
  • RN License FL 9231819 RN License NY 211299
  • American Association Professional Coders, AAPC 2013-present

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Resume Overview

School Attended

  • Hofstra University
  • Nursing Adelphi University

Job Titles Held:

  • Utilization Management Healthcare Consultant

Degrees

  • AAPC, CPC, CPB Anticipated completion
  • Masters, Business Administration, Dowling College,
  • Legal Nurse Consultant Certification
  • Bachelors

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