Summary of qualifications
Clinical Skills in ICU, Community Nursing, post acute Long Term care, in conjunction with experience with senior citizen populations, case management/disease management of Medicare and Medicaid clients, and progressive managerial responsibilities in a managed care environment have provided my career with comprehensive and well-rounded experience in the health care arena.

Professional Experience

Director of Health Services
Community Premier Plus
5/2004-present

Oversee the activities of the Health Services Department ( Case Management, Disease Management, Health Education, Quality Assurance, Utilization management) to assure that policies, procedures and regulatory requirements for each area are fulfilled.

Identify, track and trend key performance indicators across all departments
Develop corrective action plans for identified areas in need of improvement

Recruit, train, supervise and evaluate performance of all staff
Oversee Delegated Utilization management and Behavioral Health activities
Monitor and coordinate vendor activities in case management and utilization management

Oversee processing of internal appeals, external appeals and fair hearing requests

Develop and implement disease management program for providers and members

Oversee quality assurance activities, including Quality Assurance Reporting Requirements
Coordinate, create and maintain performance improvement programs

Support the education and outreach activities of the Provider Relations department

Support the Members Services department with outreach, education and complaint resolution activities

Provider staff support to the Quality Improvement Committee and the Complaint Committee, including data analysis and tracking of trends in quality and utilization

Maintain excellent working relationships with sponsor hospitals

Assure compliances with all regulatory requirements
Accountable for budget design and implementation

Other duties as required

Manager of Case Management
UNITED HEALTH GROUP: AMERICHOICE HEALTH PLAN of NJ
7/2003-5/2004
Oversees the day-to-day operations of the Case Management department.
Direct supervision of RN, MSW and coordinator staff for Medicaid and Medicare clients.
Creates, implements policy and procedure.
Ensures staff compliance with State and Federal regulatory agency standards.
Is the Liasion between the Plan and the Office of Quality Management of NJ.
Establishes the framework for all internal and external governmental quarterly and annual audits.
Evaluates, develops and motivates staff to assure successful achievement of departmental and Plan goals.
Reviews/analyzes monthly reports (daily census, enrollment, ABD/DDD, claims, pharmacy, lead) to identify case management opportunities; adjusts caseloads and or staffing.
Works very closely with the physician advisor staff on case reviews.
Vendor management. Extensive internal/external customer service.

Regional Manager Health Services Prior Authorization and Con-Current Review
CIGNA HEALTH CARE JERSEY CITY, NEW JERSEY
6/2002-7/2003
Directs the assessment and processing of all participants referred for prospective UM services
Manage the daily operations of the Prior Authorization Department
Prioritize initiatives that support the UM program and Medical Action Plan objectives
Facilitate and coach staff regarding input of appropriate UM data to assist in Hedis collection efforts
Produce, analyze, apply root cause and gap analysis to reports evidencing staff productivity, service metrics, compliance measures.
Human resource management
Lead the identification and documentation of financial outcomes for prior authorization interventions including cost benefit analysis, negotiated discounts, hard savings and the use of alternate level of care settings.
Monitors multi-state and federal legislative initiatives impacting UM.
Insures the use of appropriate clinical decision making tools: M & R, TABS, TEC.
Facilitates compliance with NCQA requirements

Director of Health and Wellness
LONG TERM CARE

THE FOUNTAINS ADULT HOME RETIREMENT COMMUNITY TUCKAHOE, NEW YORK
6/2001-3/2002
Clinical and Administrative Director of 102 assisted living units and 24 bed Alzheimerís unit
Established Nursing , Pharmacy, and Residential care models for New facility
Created onsite pharmacy program for all residents
Conducted all nursing in-services; wrote all health care related policy and procedures
Integrated home care services, physical /speech therapy, audiology, podiatry, psychiatric services onsite
Outreach to neighboring SNF and Hospitals to recruit new residents
Accountable for budget design, implementation, tracking

MANAGER, MEDICAL MANAGEMENT
MONTEFIORE CONTRACT MANAGEMENT ORGANIZATION YONKERS, NEW YORK
5/2000- 1/2001
Lead/Direct Medical Management Team for 110,000 Hip Health Plan members in the following areas:
Case Management: Prospective, Con-Current, Retrospective Review.
Responsible/Accountable for the teamís management of Home Care, SNF, Rehab, Discharge Planning Utilization management of services across all Lines of Business.
Liaison between vendors, facilities, clinicians and the team.
Designed/Implemented Operational Processes for new and existing HIP Business.
Accountable for budget design and implementation.
Developed/Implemented Policies and Procedures.
Employee hiring, performance counseling, and other employee related issues.
Developed/Implemented Training and Development Program for Medical Management Staff.
Outcomes reporting
Other related duties as assigned.

ASSOCIATE DIRECTOR CARE MANAGEMENT
HIP HEALTH PLANS NEW YORK, NEW YORK
1997-2000
Responsibilities include, but are not limited to the following:
Management of: telephone triage, pre-authorization, government
assisted programs outreach.
Direct supervision of over 100 clinical and ancillary staff.
Liaison between Senior Management and Care Management Director
Employee hiring and related employment issues
Employee training and development
Scheduling and on-call coverage
Accountable for budget design and implementation
Development of policy and procedure (work flows)
Denials, Appeals
DME (durable medical equipment)
Outcomes Reporting

NURSE MANAGER
SETTLEMENT HEALTH AND MEDICAL SERVICES
1995-1997
Supervised the delivery of patient care for a large Internal Medicine and Pediatric IPO practice.
Direct supervision of over 20 clinical and ancillary staff.
Managed recruitment and related employee relations issues.
Planned, developed and implemented staff development programs
Designed and implemented Community Outreach programs, Disease management clinics, and an emergency Asthma care station.
Managed inventory control.
Supervised an onsite laboratory

STAFF NURSE, ICU
ST. VINCENTíS MEDICAL CENTER NEW YORK, NEW YORK
1994-1995
ICU/ER patient care activities.
Charge Nurse duties as needed.

ACCOUNTS MANAGER, CUSTOMER SERVICE REPRESENTATIVE, LOAN AND SECURITIES REPRESENTATIVE
CITIBANK, NA. NEW YORK, NEW YORK
1983-1992

PER DIEM POSITIONS:

HOME CARE
JEWISH HOME AND HOSPITAL BRONX, NEW YORK
1998 -1999 (Concurrent Position, Part-time)
Responsible for data analysis for identification of appropriate case management cases.
Planning, development, coordination, implementation, and evaluation of care plans via interdisciplinary approach.
Assisted in the formal development of an interdisciplinary case management program.
Nurse Manager

LONG TERM CARE
COMPREHENSIVE CARE MANAGEMENT, NEW YORK
1998-2001
Per diem management position responsible for coordination of health
Care services rendered for Nursing Home and Lombardi Program members
Residing in Beth Abrahamís Senior residential Cluster housing.
Telephonic supervision of a team of Home Care RNs, aides, and ancillary personnel who
provide care to home care, residents and nursing home patients.

Education

Wheeling Jesuit University
BSN 2008
MSN 2009

Georgia and NY RN licenses

ST. VINCENT HOSPITAL SCHOOL OF NURSING
Diploma 1994
NYS RN licensure 1994

Other Related Skills
Excellent written and oral communication skills
Conversational Spanish
Computer Literate
Excellent Conflict Resolutionist
Knowledge of Intequal, Bischell,M &R Concurrent Review Criteria
ICD9,CPT,HCPC coding
QARR, HEDIS measures
Medicare and Medicaid regulations
Claims analysis
Working knowledge:MDS, RUGS,PPS system
References available upon request