Jane V. Evans, RN CPC

*** ***** ******** ****

Stamford, CT 06903-4219

203-***-****

E-Mail: acd79h@r.postjobfree.com

WORK HISTORY

Amerigroup, New York, NY 03/12/12 –

**/****

Title: Coordinator of Quality Management

The Coordinator Quality Management RN is responsible in conjunction with management for developing,

coordinating, implementing, and evaluating the continuous quality improvement activities throughout the

company according to the established Quality Management program. In collaboration with and under the

direction management, the Coordinator Quality Management RN - Plan establishes indicators for monitoring

and evaluating the full spectrum of care and services provided to members for quality, appropriateness,

continuous improvement and satisfaction. The Coordinator Quality Management RN - Plan provides

education in the area of quality management to all departments and assists in ensuring compliance with

regulatory and accrediting organizations.

PRIMARY RESPONSIBILITIES:

• Designs and implements quality improvement studies including selection of valid and reliable indicators

and coordinates monitoring and evaluation activities.

• Analyzes data and prepares concise, accurate and meaningful quality management reports in accordance

with company procedures.

• Actively participates in intradepartmental quality management improvement teams as appointed.

• Coordinates resolution of high level complaints.

• Educates AMERIGROUP associates about the QM process.

• Assists in defining opportunities for improvement identified through analysis of trends and

communicates these appropriately.

• Assists in the preparation for the Quality Improvement Council and other QM related committee

meetings.

• Implements, analyzes and evaluates the Company-wide inter-rater reliability program.

• Prepares QM department responses for RFIs and RFPs.

• Responsible for maintaining quality management documents, case files and correspondence in an

organized, confidential and secure manner.

• Conducts, as appropriate, oversight audits for all nationally delegated vendors.

• Develops and maintains ancillary vendor audit tools.

• Communicates significant findings, including potential risk management issues to the AVP Quality

Management as indicated in a timely manner.

• Assists with coordinating HEDIS Improvement Activities.

• Assists with coordinating Member Satisfaction Improvement activities. 16. Other duties as requested or

assigned.

Health Net, Shelton, CT 10/06 –

01/11

Title: Grievance Specialist-Appeals & Grievances

• Performs advanced and complicated case reviews to assess the appropriateness of medical care and

services provided to members.

• Point person for more complex coding cases for denial/overturn disputes.

• Provides written appeal decision to provider within 30 days of appeal receipt.

• Holds authority to overturn determinations following established guidelines, applying clinical judgment,

independent analysis and knowledge of department guidelines.

• Prepares reports, data or other materials for committee presentation.

• Prepares clinical summaries and assists legal department with litigation research.

• Researches and analyzes complex issues, acquires and reviews case documentation against clinical

records, clinical guidelines, policies, Benefit Agreement, Policy and coding guidelines.

• Develops and/or reviews determination documents and correspondence to assure accuracy and

completeness.

• Develops determination recommendations that resolve member disputes consistent with regulatory and

accrediting agencies’ requirements, and health plan objectives.

• Reports suspected fraud and abuse as required by company policy.

• Maintains confidentiality of all information in compliance with state and federal law and Health Net

Policy.

• ADDITIONALLY – In addition to my duties as Care Manager in Appeals & Grievances, I have also

volunteered to review second level appeal cases with the medical director and average 12-15 cases per

month.

Health Net, Shelton, CT 10/06

– 03/08

Title: Care Manager II – Post Service Review (MCRU – Medical Cost Review Unit)

• Advanced and complicated clinical review for inpatient, outpatient and ancillary service requests,

medical necessity appeals or claims review requests including high dollar claims after delivery of

services. Case reviews include accurate CPT and ICD-9 coding skills, determination of medical

appropriateness and medical necessity using clinical judgment, independent analysis, critical thinking,

knowledge of medical policies, and clinical guidelines.

• Contributes to company policy regarding care coverage and cost containment by identifying potential

billing abuses, inappropriate treatment patterns and ineffective procedures.

• Performs research and analysis of complex issues using multiple sources including current medical and

specialty journals, Internet review, and telephonic physician interviews.

• Conducts rate negotiation, when necessary, as per policy with non-network providers.

• Summarizes cases including analysis of medical records and appropriate application of applicable

policies and guidelines.

• Develops determination recommendations for potential denial determination.

• Identified potential TPL/COB cases.

Oxford Health Plans, Trumbull, CT 02/05 – 10/06

Title: Clinical Reviewer

Provider Compliance/SIU (Special Investigations Unit)

• Retrospective review of complex professional and institutional claims to determine medical necessity,

utilization, appropriateness of treatment and quality of care.

• Conducts comprehensive review of complex claims for medical necessity, utilization, appropriateness of

treatment and quality of care.

• Researches, identifies and monitors questionable provider utilization trends and monitors providers for

adherence to contract provisions.

• Identifies trends warranting review of current medical and payment policy and benefit coverage

clarification.

• Provides clinical support for non-clinical staff processing appeals and claims.

• Assesses medical appropriateness and quality of care by review of data and medical records to support

the approved corporate guidelines and current clinical care guidelines.

• Instrumental in recouping a $4 million dollar reimbursement from a major hospital based on close

clinical examination of billing practices.

• Clinical chart review of targeted medical specialties for potential billing irregularities.

• Clinical resource for non-clinical personnel in questions regarding fraud and/or abuse.

Oxford Health Plans, White Plains, NY 09/03

– 02/05

Title: RN Clinical Case Manager

Responsibilities:

• Responsible for case management of members enrolled in Oxford's vendor supported disease

management programs (RCC, ACE) and Oncology program. Prioritize cases daily based on clinical

necessity and nursing judgment.

• Identify and evaluate members appropriate for the case management program. Identify and evaluate

Members based on their medical need to follow-up on quality of life and quality of care issues.

• Interview member to assess individual medical and psychosocial needs to decrease utilization of

unnecessary ER and inpatient services.

• Establish a treatment plan and goals with the physician, providers, member and medical director (as

needed) to establish quality of life and quality of care issues.

• Monitor case on an ongoing basis to ensure quality of care in appropriate setting is being provided to

develop outcome measures, which are used to assess quality care.

• Identify and address changing medical and psychosocial needs of the member by follow-up phone calls

to doctor, hospital, and member to monitor patient care.

• Implement, facilitate and coordinate services for CM members.

• Active participation in Quality Management Program.

EURO RSCG Healthview Managed EDGE, New York City, NY 08/01 –

05/02

Title: Project Manager/Research Analyst

Responsibilities:

• Extensive research on pharmaceutical products and disease states as a foundation to the preparation of

marketing proposals for client companies. Extensive and focused medical/pharmaceutical literature

research using Internet, local libraries and medical academies. Departmental resource person in regard

to most current status of pipeline drug development, medical/surgical procedures and disease states.

• Created, maintained and analyzed multiple varied and specific databases containing information relating

to client lists, fees, codes and ongoing projects.

• Assist with the preparation of marketing and strategy proposals for pharmaceutical client companies

including oral and written presentations.

• Extensive and varied assistance with the development of content for educational materials including

brochures, and sales aids. Project topics have included rheumatoid arthritis, diabetes mellitus,

gastroesophageal reflux disease (GERD), deep vein thrombophlebitis (DVT), and antibiotic resistance.

• Ability to locate, use and analyze CPT and ICD-9 coding both in literature and billing.

Purdue Pharma, L.P., Stamford, CT 09/00 – 03/01

Title: Coordinator, Contract Maintenance

Responsibilities:

• Determined discount pricing eligibility by in depth research on requesting facilities.

• Daily communication with drug vendors regarding billing and contracts. Extensive, detailed

documentation on each facility per company and federal standards.

• Reviewed and maintained multiple membership lists for group purchasing organizations

necessitating continuous, timely and accurate updates.

Oxford Health Plans, Norwalk, CT / White Plains, NY 01/93

– 05/01

Title: Administrative Research Reporting Analyst

Responsibilities:

• Created, maintained and analyzed multiple varied and specific databases containing information relating

to client lists, fees, codes and ongoing projects.

• Ordered, distributed, maintained and accounted for all department office supplies.

• Organized, scheduled and facilitated multiple committee meeting, assisting at meeting with notes, visual

aids, conference calling and follow-up.

• Maintained department reference library including ordering new books, journals etc. Maintained

checkout responsibility. Tracked and recovered missing material. Researched and made suggestions

regarding new purchases and subscriptions.

• Extensive Net research on request for various clients on various topics with reports being generated in a

variety of formats.

• Acted as research contact person for medical, pharmaceutical and home care clients requesting

information on disease treatment.

• Heavy client contact via phone, e-mail concerning requests, reporting results and following up.

• Responsible for researching, collecting and compiling data from a variety of sources creating databases,

charts and graphs to facilitate analysis and process improvement. Data written up as summaries for

senior management for use in policy formation.

• Enhanced accuracy and timeliness of reporting by creation of templates used company-wide.

Metropolitan Life Insurance Company, Westport, CT 1988

– 1993

Title: Utilization Review Coordinator

Responsibilities:

• Administered all health benefits plans for NYNEX employees including precertification, hospital

utilization and home care follow-up.

• Extensive communication with patients, physicians, and hospital administration to obtain information

necessary to extend benefits to their maximum potential.

Stamford Hospital, Department of Medical Records, Stamford, CT 1974-1988

Title: Medical Transcriptionist

Responsibilities:

• Transcribed large volume of dictation from all medical specialties.

• Trained new transcriptionists in medical terminology and office procedures.

Greenwich Hospital, Greenwich, CT 1985 –

1988

Title: Registered Staff Nurse

Responsibilities:

• Performed timely and accurate patient care under physician guidance. Instructed student nurses.

Oriented newly graduated physicians to floor procedures and hospital guidelines.

Norwalk Hospital, Norwalk, CT

1977 – 1984

Title: Registered Staff Nurse

Responsibilities:

• Performed timely and accurate patient care under physician guidance. Instructed student nurses.

Oriented newly graduated physicians to floor procedures and hospital guidelines.

EDUCATION:

Central Connecticut State University, New Britain, CT 1970 –

1974

Bachelor’s Degree – English / Education

Norwalk Community Technical College, Norwalk, CT

1975 – 1977

Associates Degree – Nursing.

New York Medical Academy, New York City 2002

Internet researching methods.

AAPC-Sponsored Professional Coding Course

Certified Professional Coder

LICENSES/CERTFICATIONS:

Registered Nurse:

• Connecticut E-39229

• New York 555754

Certified Professional Coder

• CPC/AAPC 01058670

AFFILIATIONS:

• International MENSA

• Who’s Who of Business Professionals

• AHIMA

• AAPC

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