Description
Summary of Qualifications: I have worked in Managed Care in the business arena for twenty years. My objective is to have a position with an organization which will allow me to be in a position within the Health Plan industry and be responsible for supporting associates and an institution to increase the profitability. This would allow me to integrate my extensive background in clinical nursing, training, sales/ marketing presentations, quality management, contracting, case/ disease/ utilization management, and advocate the principles of managed care concepts with my excellent customer service, and analytical skills. I have been employed in the Commercial, Medicare, and Medicaid arena and look forward to an interview. and * I was responsible for the development, implementation, and management of case and disease management departments. I had direct supervision for daily operations of personnel, 35 direct reports. Support the provision of high quality, cost-effective clinical care in efficacious relationships with health care providers. To develop new program components to address identified needs within health services domain. * Provide direct day-to-day supervision of the staff in general case and disease management resources and participate in determining the department's organizational structure, staffing, and space planning requirements. * Provide daily programmatic direction and assistance to statewide/ regionally staff including monitoring of workflow, productivity, enrollment, and outcomes data, including conduct statewide coordination meetings as mechanism for communication of new and revised procedures and problem-solving. * A Resource Conductor to other departments for clinical and non-clinical situations. * Participate as a member of Health Improvement Management team and collaborate with appropriate Medical Directors from the Physician Operation Delivery, POD Directors, and Physician Champions as appropriate. * Communicate and collaborate with disease management providers and assess all elements being provided in the network and to provide budget recommendations to management regarding the need for staff, equipment, and other resources based upon diagnosis and length of stay reports and made case/disease management assignments. * Reviewed and chaired catastrophic cases weekly with staff and discuss reporting applications and assists in decision making for appropriateness of treatment and interfacing with matrix partners. * Reviewed and audit staff performance on a routine basis to insure the staff adherence to the guidelines of case and disease management and conducts positive counseling as necessary and maintains written documentation. * Performed annual performance reviews for case and disease management and interviewed candidates for case management and disease management positions and made recommendations for hiring. * Provide trended activities on a quarterly basis to the UM Director of Health Services Affairs. * Developed policies and procedures, training, clinical educational modules, manuals, tools, and job aids when necessary to obtain and distribute ongoing clinical education for statewide and regional case/disease management teams. * Monitored enrollment, outcomes, and satisfaction for the physicians and members. * Identified measurable productivity areas and monitor productivity and efficiency. * Responsible for managing Disease Management programs with third party vendors and developing Coronary Heart Disease, and End Stage Renal Disease programs for the Healthplan. * Responsible for hiring, developing, and retaining quality personnel along with presenting HIPPA regulations to the company via new hire orientation and responsible for maintaining and developing Authorization for Release of Information database. * Involved in Community outreach programs: American Diabetes Association, Corporate Team Leader for two years, and raised total 43k. Texas Medical Foundation, Lipid Project for the African American with Diabetes. National Hispanic Council on Aging Houston Chapter, and the Elder Service Provider's Network. I provide presentations to the community on disease state concerns, empowerment, and education. KS. * Responsible for Disease State Management programs. Monitor and evaluate program operations by identify coordinate present and develop initiatives to strengthen program objectives to improve clinical outcomes and medical cost. Work with Corporate Medical Directors and other internal matrix partners in developing action plans to promote value and drive integration of the Disease management program to our internal and external customers. Responsible for hiring developing and retaining quality personnel. Assisted in preparations for the HEDIS/ NCQA Accreditation. * Participate in corporate sponsored task force committees involved in second level appeals committee diversity committee medical management committee medical advisory committee and the quality management/NCQA committee.
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