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Management Manager

Location:
San Francisco, CA
Posted:
July 25, 2015

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Resume:

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



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