Medical and Workers Comp Case Management, Case Management Admin.,HEDIS
Resume:
VICKI RHNY WISDOM R.N., C.C.M.
Antioch, TN 37013
Email: acr9ck@r.postjobfree.com
1
HIGHLIGHTS OF EXPERIENCE
HEALTH PLAN MANAGEMENT/CASE MANAGEMENT/CLAIMS
Utilization Management/Quality Improvement/MCO Appeals Workers Compensation Field/Telephonic Case Management/Director Alternate Dispute Resolution/Mediation
Medical Claims Review Consultant/Medical Bill Review Legal/Medical Standard of Care Reviews
Liability Review Nurse –Auto, Homeowners, Group Liability, Premise Liability Correctional Healthcare Management, Administration Project Management/Program Development
Audit Manager /Trainer– Interqual/Milliman criteria Corporate Director of Health Services – Medicare Advantage Plan Program Director Acute/Chronic Case Management
Member of NCQA/HEDIS Task Force/HEDIS auditor
Long Term Care Support Services
TRAINING/INSTRUCTIONAL DESIGN
National Manager, Corporate Clinical Training Team Clinical Training Specialist/Regional Trainer
Instructional Design Clinical Training Programs
CLINICAL
Medical and Workers Compensation Case Management
Medical/Surgical/Orthopedic/Nursing
Home Health Care/Infusion Therapy
Long Term Care Geriatrics
Occupational Health Nursing
Correctional Healthcare
TECHNOLOGY
Experienced user MS Office Suite, Lotus Notes, Outlook, ERMA Experienced user MaCess, CSC, Internet, CLASS, Care Planner, Care One, CCMS, Claims Zone, SharePoint, FACETS PROFESSIONAL HISTORY
Correct Care Solutions (1/2013 – 7/2015)
Vice – President of Care Management
Senior leader of corporate Care Management initiatives and core processes
Implementation and management of Medical Review program including SOP and DB application, resulting in 1.6M savings through 7/15
Decreased average length of stay (ALOS) in correctional inpatient population by 12.6% resulting in a decrease of 10% from national average
Clinical and administrative oversight of corporate Care Management program and initiatives
Budgetary compliance and management
Director, Care Management
Oversight of Care Management division to include remote staff management, achievement of divisional goals supporting corporate balanced scorecard, and support of Care Management vision
Collaborated with executive, clinical and operational leadership in the development of application enhancements to support Care Management initiatives
Development, maintenance, implementation, and publication of Care Management departmental policies and procedures
Regional Care Manager
Utilization Management of inpatient stays utilizing Interqual criteria in regional assignment
Management of care transitions with site clinical staff VICKI RHNY WISDOM R.N., C.C.M.
112 Brentridge Drive
Antioch, TN 37013
Email: acr9ck@r.postjobfree.com
2
Blue Cross Blue Shield – Volunteer State Health Plan (4/2012 – 1/2013) Operations Manager, CHOICES Program
Long Term Care program providing services in the home/community setting to target population
Responsible for operational accountability of Support Center program to the Bureau of TennCare
Operational management of program including service authorization, TennCare eligibility submissions, referral and screening programs; Team of 62 employees/Manager
Oversight of Quality program including Critical Incident Reporting, Process Improvement Projects, and Continuous Quality Improvement
Independent Clinical Nurse Consultant (2/2011 – 4/2012)
Nurse Consult providing case management services (medical and workers’ compensation), adjuster/claims training programs and medical claims consulting
Training programs included anatomy/physiology for claims adjuster, setting appropriate reserves, determining causal relationship, and biomechanics
Contract HEDIS auditor
HealthSpring, Inc. (4/2008 – 2/2011)
Coding Education Consultant
Consultant providing project management, program development, training and instructional design
ICD-10 Training program development and presentation Corporate Director of Health Services
Director clinical administration CCMS medical management system including Interqual criteria
Development/maintenance of corporate health services SharePoint sites
Successfully led development/implementation of integrated medical/behavioral care management
Led development of quality/compliance audit tools
Led development/publication of corporate health services policies and procedures
Design, development, delivery, assessment of corporate health services clinical training programs
Led corporate team in development/implementation of educational material for over 200,000 members AmeriChoice - United Health Group (2/2007 – 3/2008) Manager National Training Team, Clinical Trainer
Recruited to design/implement clinical training program for startup MCO including UM/Case Management
Promoted to Corporate National Trainer within 2 months
Promoted to Manager of National Training Team within 6 months; 7 remote clinical trainers
Facilitated employee training and functional development to meet or surpass performance expectations in support of corporate mission and employee integration into the culture
Successfully led design, development, delivery, and assessment of training and educational programs to increase overall corporate performance
Collaborated with department heads to develop core competencies and align competencies with human resource processes, clinical best practices, and regulatory compliance Nationwide Insurance Company (2003-2007)
Claims Medical Specialist
Medical review of casualty claims/composition of technical reports
Consultant to litigation staff in alternate dispute resolution/depositions
Casualty medical claims support in multi-state jurisdictions
Regional medical trainer in various environments/training formats
Instructional design of corporate clinical training programs for adjusters InServices, Inc. (1998-2003)
Field Nurse Case Manager; Workers Compensation/Medical
Field/telephonic case manager; clients in multi-state jurisdictions
Responsible for utilization management/case management return to work programs
Employer account management/training programs
VICKI RHNY WISDOM R.N., C.C.M.
112 Brentridge Drive
Antioch, TN 37013
Email: acr9ck@r.postjobfree.com
3
CARITEN (1994-1998)
Director of Medical Case Management
Created/implemented medical case management department
Recruited/trained case management staff
Achieved EQRO (state QI program) approval of TennCare departmental policies/procedures
Created/implemented regional utilization management process for outpatient rehabilitation therapies
Served as consultant to sales/marketing/network operations/acute care case management staff
Program Director Disease Management; co-created/implemented DM programs with CMO Comprehensive Rehabilitation Associates (1991-1994) Field Nurse Case Manager; Workers Compensation/Medical
Workers compensation telephonic and onsite case management
Promoted to senior manager within four months of employment
Medical Bill Review
Intracorp; CIGNA (1985-1991)
Account Manager/Case Manager/Audit Manager
Account Manager for acquisition/service of case management contracts
Consultant performing medical/rehab case management/legal medical reviews/utilization management
Promoted and relocated to Nashville, TN as Audit Manager (six remote direct reports)
Developed/implemented process for auto liability case management and medical bill review Appalachian National Life Insurance Company (1982-1985) Director of Claims Cost Management
Developed claim review procedures for surgical, medical, chiropractic, disability claims
Conducted coding clinics for claims staff
Created training programs for benefit/plan discussions at employer worksite
Chairman of Benefit Interpretation Committee
Created/Implemented marketing materials for case management plan benefits
Regional account trainer for group benefit utilization EDUCATION
St. Mary’s School of Nursing, Knoxville, Tennessee (1972-1975) Diploma of Nursing; Registered Nurse licensure 1975 CERTIFICATIONS
Certified Case Manager Certification 1994; Recertification 1999, 2004, 2009, 2014 Project Management Certification; Health Spring Enterprise Project Management Office; 2009 Group Facilitator Certification, Oasis Institute; 2001 Member, Case Management Society of America
AWARDS
Creative Writing Award, 1971
Excellence in Care Nomination, 1978
McKesson National Conference Speaker, 2009
Integration of Medical and Behavioral Health in the Medicare Advantage Environment VOLUNTEER PARTICIPATION
Chairman, Outreach/Missions Committee – Liberty United Methodist Church Second Harvest Food Bank
References and Clinical Resume available upon request
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