Karyn Warrington, RN, BSN

*** ********* ****, ****** ****, NY 11558 • 516-***-**** • acqtoz@r.postjobfree.com

Director of Case Management and Clinical Services

Accomplished, highly motivated registered nurse with more than fifteen years of management experience in managed care and case management, financial recovery, disease/population management, and long term care programs. Excellent leadership abilities, problem solving skills and expertise in multiple areas along the health care continuum

Professional Experience

Director of Clinical Services

Elderplan / HomeFirst, Long Term Managed Care, Brooklyn, NY July 2013 – March 2015

Manage and Direct staff of 80 fulltime employees

Responsible for:

oInpatient Case Management (Medicare/Medicaid/MAP/MLTC)

oSNF Case Management (Medicare/Medicaid/MAP/MLTC)

oPre-Certification

oCommunity Case Management/Care Management, Medicare

oCall Center which is responsible for the placement and authorization of Medicaid DME and PCW services

Health Coach Program- pilot DSRIP program which involved educated, non-clinical staff with an independent case load with the goal of decreasing hospitalizations and readmissions

Initiated intensive Care Management Program based on Coleman model of care

Medicare pilot case management program that provides increased home care services for a high risk population, with the goal of decreasing hospitalizations and emergency room visits.

Discharge planning and follow up.

oLiaison for CHHA, Palliative, and Hospice programs and Inpatient and SNF case management, Medicare care management

Senior Business Analyst, Recovery and Prevention (Consultant)

NY Downtown Hospital, New York, NY July 2012 – July 2013

Provided recommendations, leading to maximization of revenue, improved workflow, and reduced denials Managed, coordinated, tracked and appealed clinical denials.

Responsible for workflow, including billing of, and clinical determination of Observation cases

Acted as liaison between clinical and financial departments

Tracked and trended RAC denials and made institutional recommendations based on analysis of data

Director of Case Management, Recovery, and Prevention

St. John’s Episcopal Hospital, New York, NY July 2008 – Feb. 2012

Identified opportunities to reduce financial risk and maximize revenue

Acted as liaison/bridge for Clinical and Financial departments

Provided leadership and acted as a resource for case managers (staff of 10-15)

Planned, directed, and implemented hospital-wide Case Management Program

Acted as liaison for hospital with medical staff, finance, admissions, HIM, social work, nursing, regulatory and external review agencies, third-party payers, community health, welfare and other services

Coordinated programs among departments and services that assessed the quality and appropriateness of care, appropriateness of admissions, continued hospitalizations and readmissions

Monitored length of stay, case mix index and other reimbursement/financial indicators in order to recommend and implement hospital-wide improvement strategies

Responsible for denials management

Decreased length of stay on medical-surgical units by .5 days for 3 consecutive years

Restructured department, designed role of ER case manager and initiated and trained emergency room case managers

Successfully identified potential hospital savings exceeding 6 million dollars annually for three consecutive years. Maximized revenue

Established relationships with area nursing homes, improving communication, decreasing length of stay and reducing readmissions

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Professional Experience

Various temp and contract positions Sept 2006-July 2008

HMO case management

Hemodialysis Center Administrator/Director

Appeals Manager

Forest Hills Hospital, Queens, NY Jan. 2006 – Sep. 2006

Responsible for all aspects of Denials and Appeals. Turned around appeals process which was running at loss.

Demonstrated cost savings of 1.9 million dollars in 7 months; overturn rate of 54%

Canopy Systems Administrator and super user

Participant in NSUH -system Revenue Cycle and Canopy committee

Director of Quality Improvement

St. Johnland Nursing Center, Kings Park, NY July 2005 – Jan. 2006

Responsible for QA/QI activities throughout 250 bed LTC facility including sub-acute brain trauma unit

Planned, taught, initiated and monitored facility response to new regulations.

Developed and initiated reporting tool for infection control and database for infection control monitoring

Investigated, tracked, and trended accident reports

Initiated and chaired various QI Committees

Acting Director of Nursing

Menorah Home and Hospital, Brooklyn, NY April 2004 – July 2005

Participated in all activities related to general operations of a 206-bed facility with vent unit

Contract position until closure of SNF

Responsible for implementing and organizing all policies, practices and services of Nursing Services

Supervised all nursing staff, approx 159 employees

Medicaid Case Manager / Clinical Appeals Coordinator

HIP, New York, NY 2001 – 2004

Provided comprehensive management of Medicaid members: assessment, care planning, implementation and coordination of community services in partnership with member and providers

Ensured timely and accurate resolution of all Complaints, Appeals and Grievance issues requiring medical necessity review, generated through member services, members, and/or physicians’ verbal or written complaints

Conducted chart review, identifying issues and trends warranting review of current policy, procedure, and benefit clarification

Oversaw communication with Medical Management and Claims to ensure accuracy in resolving discrepancies

Reported appeals outcomes/decisions and other requested documentation per the terms of the delegated agreements to HMO partners

Tracked and reported monthly issue turnaround time performance and recommend actions based on ongoing analysis

Identified opportunities for quality improvement and cost savings

General Manager Provider Relations

Fedsure Health, Johannesburg, South Africa April 2000 – Dec. 2000

Integrated newly acquired companies/networks for plan with membership in excess of 1 million people

Contract negotiation and implementation

Initiated and managed the first public-private healthcare partnership in South Africa

Reorganized and restructured Provider Relations Department

Executive Managed Care Advisor to integrated HMO (network provider groups, HMO, clinics, pharmaceutical company)

Managed Care Consultant

Liberty Life/Liberty Healthcare, Johannesburg, South Africa Oct. 1996 – April 2000

Directed the company’s response to legislative changes in South Africa

Strong project management

Developed a five year corporate managed care plan including: philosophy, strategy, infrastructure, systems, claims work flow, team development, training, staffing for pre-authorization, case management, disease manage-ment, chronic medication benefit, and drug utilization review

Edited member and provider communication, nationally recognized for clarity in insurance writing

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Professional Experience

Editor, Internet Healthcare Industry Newsletter

In-house HMO trustee

Assistant Manager, Managed Care

Discovery Health (HMO), Johannesburg, South Africa Aug. 1995 – Oct. 1996

Development of rapidly growing managed care department (the first in South Africa) including development and implementation of managed care, drug utilization review, chronic medicine benefits, and HIV/Aids benefits.

Chaired Medical and Dental panels

Responsible for supplier relationships and hospital liaison

Developed and implemented the first managed maternity program in Southern Africa

Managing Director, Public Health Clinic 1983-1989

Tel Aviv, Israel

Responsible for all aspects of health care for 10,000 lives, based on British district system

oPrimary care physician

oDisease Management

oDiagnostics

oPre-operative preparation

oPost hospitalization care, including home visits and coordination of other services

oRN home visits

Initiated and ran the first needle exchange program in Israel

Education

Bachelor of Science, Nursing

Adelphi University School of Nursing, New York, NY

Professional Associations and Services

Executive Officer, Case Managers Association of Southern Africa

Health Care Advisor, South African Department of Health, and Legislative Committees

Lecturer, Managed Care at Pretoria University

National Speaker on Southern African Healthcare, Managed Care, and Women in the Corporate Environment

Published, American Managed Care journals

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