Donna Reed Moore
Panama City Florida 32405
Home: 850-***-**** Cell: 850-***-****
Email: acqxc6@r.postjobfree.com
Active Florida/Ohio/Kentucky RN license
CA/New York license application in process
Education
Bachelors of Science, Nursing
CCM Certification
ACLS
BLS
Strength
To obtain a position with a company in which I can use my 40 years of nursing experience and thirty years of Case Management in hospital operations, insurance, hospice, rehabilitation and consulting practice to assist in achieving maximum, sustainable, implementable improvements and secure a higher level of cost effective care, performance improvement and, patient safety and outcome management for continuous quality improvement.
Experience
November2014-March 2015 Bayhealth Medical Center and Milford Memorial Hospital Interim Director of Case Management/Consultant Assessment of current department with recommended implementations to improve efficiency of the department and staff. Development of ED Case Management program to assess appropriateness of each admission and divert as needed. Redefine roles and retrain in case management and social work roles. Denial/appeals management Develop community resources to avoid readmissions and lower LOS Tracking of avoidable days Physician engagement and education with development and implementation of LOS rounds and scorecards.
Daily reviews with IQ within 24 hours of admission
Obtain a Physician Advisor to assist staff
April 2014-June 2014 Erie County Medical Center
Interim VP of Integrated Services
Expert leadership to hospital case management, psychiatric case management and utilization review departments totally 123 FTE’s to ensure effective patient care by educating them in their new role in the Care Continuum and Resource Management process. We improved efficiency of workflows, resource management and delivery of cost-effective patient care. Daily Rounds with floor physicians were initiated and lead by Case Management to ensure patient progression and effective discharge planning. We assisted the Bed Control Area to begin cohorting the patients to specific floors to reduce the number of services and physicians present on each unit. We worked together with the CDI experts to develop a daily working DRG and monitored it to reflect any change in the patient’s condition increasing our CMI from 1.5 to 2.8. We developed daily rounds for all case managers to meet with our two Physician Advisors to discuss barriers for discharge for patients in the 3-10 day range. In addition, we began a SWAT team which met weekly to discuss cases greater than 20 days with a resulting lowering of long stay population. In addition, we hired new case managers and discharge planners and implemented an effective ED program that assured patient’s met medical necessity, were in the correct status and assessments were completed in the ED with the patient being placed in the correct bed. Case Managers learned how to handle patients that did not meet for admission lowering the readmission rate. We evaluated resource consumption with the goal of lowering cost per adjusted admission. Community Meetings were started with all available area resources to determine an effective communication process, develop good working relationships and a care management strategy to assist each other through the continuum of care.
November 2013 – February Sutter Health Care Eden Medical Center-NHS Solutions
Interim Director of Case Management/Consultant
Interim Director evolving to Consultant to train an internal candidate for the Director position. Supervised 44 FTEs in Case Management, Social Work, Chaplains and CM Assistants, Redefined roles and responsibilities, Provided leadership, staffing and attendance oversight, budgetary responsibility, policy initiative, denial management and possible 4/10 hour shifts with pay increases. Developed community resources and networks to ensure patient’s safe, efficient transitions to home which decreased LOS, avoidable days, readmissions, denials, and increased communication and team involvement. Assessed department model with new roles for CM assistants to perform new duties to lighten the CM roles. Implemented a long term clinical and financial model for cost effective care. Team daily rounding with physician, palliative care, nursing, SNF/HHC and patient/family involvement to improve communication and lower LOS, through-put, training, staff with IQ reviews completed within 24 hours of admission with appropriate status and billing, concurrent review as required, RAC audits, IPPS changes, physician teaching, IQ trained House Supervisors.
Evaluation of ED CM role with recommended changes for ED Care Coordination Initiatives
September 2013-November 2013 HCA Riverside Community Hospital through Nielsen Agency
Interim Director of Case Management/Consultant
On the provider side:
Oversight, management, development and motivation of 50+ RN’s/Social Work case managers
ALOS 3.4 days.
Medical necessity/case management education/training on InterQual guidelines. Monitor per McKesson guidelines.
Root-cause analysis.
Process improvement.
Program development, e.g. create effective denial/appeals process.
Facilitate collaboration across interdependent departments, with a focus on improving HCAHPS results.
On the payer side:
Develop and oversee medical management strategies and initiatives for
50k Medicaid and Medicare members
URAC-accredited health plan; including high volume Utilization
Management and Care Coordination.
Manage/develop staff for quality and productivity.
Demonstrate effective leadership to optimize team performance.
Manage change and encourage innovation, eliminate silos, build
collaborative relationships.
May 2013-August 2013 Cooley Dickinson Hospital-The Clinical Recruiter Michelle Boeckmann
Interim Director of Case Management/Consultant
Changed the current Case Management model
Organize resource utilization
Concentrate on financial performance while driving strategic growth.
Extensive training and education to prepare staff for changes in their roles.
Converted UM staff to case management role. .
January 2013-April 2013 Temple University Hospital
Interim Case Management Director/Consultant-Leaders For Today
I was able to assess and recommend operational changes at the facility.
I was able to lower the length of stay by 1.5 days in six weeks
Decrease readmissions by 6%
Combined and trained the Utilization Review Department and the Case Management Department to perform as case managers performing Care Coordination.
Stabilized the staff until a permanent replacement was hired.
June 2012 -December 2012 HCA Rio Grande Regional Hospital
Interim Case Management Director-Nielsen Healthcare
With an understanding of the intricate components of care coordination across the continuum, I used my leadership and operational experience with financial analysis, physician engagement, and care coordination perspective to facilitate transformational change.
Ability to bring continuity and stability of operations until a permanent replacement is not only located, but also ready to assume responsibilities of the position.
Provide an objective viewpoint that leads to customized action plans and solutions
Guaranteed leadership with a flexible timeframe based on your specific needs
Help maintain staff confidence
Continuation of efficient and strategic operations Improved outcomes, core measures, best practices and customer and employee satisfaction scores
Smooth transition while a permanent leader is being identified and during preparations for a change in leadership
Support safe, appropriate, and cost effective care provided in the appropriate setting to qualify for reimbursement
Early identification of discharge needs
Knowledge of utilization management-RAC and third party payers
Monitor statuses to assure medical necessity
November 2011 -February 2012 IMA Consulting
Strategic Consultant
Provided leadership, accurate objective assessment and explicit operational work plan to help hospitals attain best in class status in Case Management Department.
Ability to bring competency, innovation, and integrity to transforming the work environment.
Qualified to ensure hospitals diagnose and improve hospital and clinical performance.
Determine leadership capabilities, staffing model, delivery processes, policies, interdepartmental dependencies and practices within each facility.
Assessed reporting structure to higher management.
Determined approaches to increase revenue for each facility through denial management.
Develop current practices to improve the performance of the department at each facility.
Assess staffing needs and best use of each employee to promote cost effective quality care.
Member of clinical operations team assisting healthcare clients to position and create flourishing, sustainable, performance driven departments.
June 2011-September 2011 HCA Division
HCA Hospital Consult/Case Management
Evaluate, monitor and analyze division facility’s direction. Direction of all facets of Care Coordination Management and Utilization Management.
Able to assess and recommend operational changes at each facility so they were under budget for first time in six years.
Evaluate, design and implement a long term clinical/financial model to assure a cost effective, efficient model execution.
Assess performance in customer relations, medical necessity, resource utilization, length of stay. Facilitate coordination of cost effective care according to Corporate/ Division/ facility goals/objectives.
Planning, directing and managing the department and staff to assure quality service on a 24 hour basis.
Meets JCAHO/CMS standards, comply with corporate policy and procedures, promote teamwork with physicians/ all health care providers, promote internal/external customer satisfaction, and appropriate resource management.
Provides facility specific LOS analysis. Recommend process improvement.
Coordinates compliance initiatives with outside agencies (FMQAI). Intervenes with managed care companies to address and resolve issues related to facility utilization review process.
Identifies educational opportunities. Coordinate division/facility based training programs.
Monitors and analyzes trends in the appeals/denials process.
Develops plans to minimize future denials. Facilitates development/review of division/facility UM plans to comply with state/federal regulatory requirements. Maintains working knowledge of national criteria, Milliman / Interqual, to assist in criteria review activities for facilities.
April 2010-June 2011 HCA North Florida Division
Division Director Case Management
Leadership to 14 Division Facility Executive Staff and Facility Case
Management Directors with Care Coordination and Utilization Management Issues.
Identify, implement or enhance CM programs consistent with facility strategy.
Monthly HCA Group meetings to provide clinical updates and discuss support plans.
Eastern Group Care Coordination Initiative ED and ICU Focus for 2011
Division Implementation and training of Executive Health Resources at fourteen facilities
Assess and monitor CM/UM performance in assigned facilities.
Disseminates information accurately/timely with multiple audiences, has scheduled communication sessions with facility CM Directors.
Identifies and shares best practices with division/company.
Develop, revise and implement CM policy and procedures.
Implement regulatory requirements, ethics and compliance policies and quality initiatives.
Facilitate communication and collaboration between facilities CM, PAS and other departments.
Facilitate Case Management education within the Division.
Data analysis of Case Management Metrics related to denials, avoidable days, LOS, readmits.
Develop resource reduction strategies with a focus on quality outcomes, reducing LOS, medical necessity and level of care.
Design and monitor facility processes to ensure appropriate determinations are obtained from all payer sources, decrease denials.
August 2004-April 2010 HCA Gulf Coast Medical Center Panama City, Florida
Director of Case Management
Monitor, educate and support the knowledge, skills and performance of the case management staff.
Implement CMSA Standards, URAC guidelines, Code of Professional Conduct for CM, Federal regulations on confidentiality and GCMC facility policies, procedures and organizational goals.
Plan, develop, implement, evaluate and refine case management intervention. Support a culture of continuous quality improvement.
Supervise CM performance, educate coordination of care and service across a continuum of illness, empower case managers by promoting effective utilization of healthcare resources, leadership to achieve optimal clinical/resource outcomes, teach multidisciplinary approach to provide appropriate cost effective care in a timely manner.
Develop philosophy, goals and objectives for concurrent CM performance that meets clinical and financial requirements.
Develop and maintain a positive work environment.
Identify patterns/trends with potential for adverse impact. Develop corrective actions plans and reevaluations of outcomes.
2007-2008 House Supervisor
2004-2007 ER Case Manager
2003-2004 Hospice of the Emerald Coast Panama City, Florida
Office Manager/ Admissions Specialist/ Field Case Manager
Admit/determine hospice plan of care within federal guidelines
Managed office and staff activities.
1995-2003 Anthem Blue Cross and Blue Shield Cincinnati, Ohio
State/National Hospice Director, Regional Case Manager
Developed Hospice program for Midwest Division including authoring
Corporate guidelines, policies and procedures, negotiating contracts
Speaker at State Hospice Convention
Onsite educational liaison between Doctors, Hospitals, Staff, Patients
and insurance company
Individual case management/ quality improvement/utilization
management to provide cost effective quality care
1994-1995 HealthSouth Rehabilitation Hospital
Case Manager, Program Director Stroke and Brain Injury Team
Coordination, discharge planning, development/ certification of
Plan of Care
Community/ financial resource management/development
Director of Case Conferences determining patients care
1993-1994 Vitas Hospice Cincinnati, Ohio
Patient Care Manager, Admission/Field Nurse
Complete admission plan of care and appropriate intervention
Precertification and negotiate with third party payer
1992-1994 St. Luke Hospital West Florence, Kentucky
Emergency Room Nurse
Initial assessment, triage and treatment of acute and trauma
Patients
1981-1993 University Hospital Cincinnati, Ohio
Staff Nurse Float Pool, Admissions Nurse, UM/ QA Nurse
Float Nurse for MICU, SICU, NICU Level 3, BURNS, CCU,NEURO ICU
Quality Assurance/Utilization Review
Educational resource, triage/precertification/reimbursement specialist
Trending/tracking of physician data to determine best practice protocols
Developed hospital critical pathways for target DRGs
1978-1981 St. Elizabeth Hospital Edgewood, Kentucky
Staff Nurse
Management/ Charge Nurse Medical Surgical/ Pediatric Units
1975-1978 Booth Memorial Hospital Covington, Kentucky
Head Nurse Psychiatric Unit/Float Pool Nurse
Director of staff and management of budget
1974-1975 Christ Hospital Cincinnati, Ohio
Staff/ Nurse/ Charge Nurse on Medical Surgical Unit