Yvonne Fernandes, BSN, RN, CCM, CMCN

***-** ********* *********

Saint Albans, NY 11412

718-***-****/917-***-****

acvcae@r.postjobfree.com

Experience:

**/**** ** **/****

SUNY Downstate Medical Center

Director of Care Management

Oversaw Care Management which consisted of Case Managers, Social Workers/Discharge Planners and Clinical Documentation Specialists.

Planned, developed, organized, implemented, evaluated and administered Care Management programs and initiatives in accordance with objectives of hospital administration and medical staff.

Participated in the development of effective hospital-wide Care Management strategies, ensuring compliance with external accrediting agencies and patient care review requirements including but not limited to JC and IPRO.

Ensured compliance regarding resource allocation, discharge planning and social work intervention processes in accordance with regulatory agencies including but not limited to DOH, TJC, CMS, IPRO, OMH and other local bodies of authority, and acts as a liaison for the same.

Supervised the integration of the activities of the departments assigned so the objectives of the Care Management programs were accomplished.

Provided mechanism for discharge planning via hospital-wide implementation of Care Management plan and updated high risk screening criteria on an ongoing basis in order to capture the needs of the community.

Tracked and analyzed data generated through internal and external sources such as patient care evaluation studies, length of stay, variance analysis, financial reports, departmental reviews and other operational reports for the purpose of clearly identifying issues.

Coordinated and participated in special multi-disciplinary projects with appropriate hospital staff.

Collaborated with and provided technical and consultative support to Chiefs of Service, Chief Medical Officer and other administrative positions.

Collaborated with hospital administration in identifying areas of concern and improvement based on case mix, length of stay and other variance analyses.

Presented as the resource person for all hospital employees and medical staff regarding Care Management.

Maintained up-to-date departmental operations policies and procedures.

Demonstrated leadership skills for all personnel within departments including assessing potential problems or risks and addressing them.

Supported and provided clear direction and priorities for staff within department to ensure high departmental productivity and functionality.

Served, in conjunction with the physician champion, as a resource for difficult Care Management cases to departmental staff.

Represented Care Management and participated in appropriate hospital meetings including but not limited to Provision of Care, Revenue Cycle, Utilization review and Patient Throughput Committees.

Managed fiscal and human resources in an efficient manner in accordance with the departmental budget.

9/2012-10/2014

North Shore LIJ Medical Center

Assistant Director of Case Management

Oversaw the daily functions of Case Management Services inclusive of concurrent review, discharge planning, and denial and appeals

Assisted with systems, processes, and outcomes of clinical care teams and programs designed to address clinical, psychosocial, and financial needs of patients and families

Participated in training, supervision and evaluation of team members

Participated in goal setting, program planning, workflow process monitoring, regulatory compliance, staff productivity, and assessment of good customer service, quality of work, outcome evaluation, and continuous quality improvement

Represented the organization to internal and external customers including patients and families, physicians and ancillary medical personnel, service leadership, administration, other sister hospitals, health plans and other third-party payers

Along with senior administrative director, collaborated with hospital directors and establish goals and objectives for the department

Developed strategies and programs to achieve goals

Developed and implemented policies and procedures supporting quality patient driven care through efficient and effective case management

Guided, mentored, motivated and engaged the staff in assessing, planning, implementing programs and evaluating patient care according to patient satisfaction and positive outcomes

Screened and investigated case management incidents and patient complaints and determined follow up and initiated corrective action

Assessed staff’s ability to manage and analyze patients total care needs across the continuum and developed short and long term goals

Collaborated with Patient Accounts/Finance, HIM, CDI leadership to maximize reimbursement

Oversees denial and appeals process inclusive of RAC, MAC and IPRO

Interviewed, hired, developed, managed and evaluated direct reports as well as interacted and collaborated with the interdisciplinary team

Promoted and encouraged staff development and education

Established standards for performance and ensured timely completion of performance appraisals

Audited staff work and ensured criteria and guidelines were followed that supported evidence base practice

10/10-9/2012

Amerigroup Community Care

Director HCMS-UM

Oversaw the daily functions of Health Care Management Services inclusive of pre-certification, concurrent review, discharge planning, and denial and appeals

Oversaw review of concurrent, and retrospective review cases in conjunction with reviewing high-dollar cost outlier claims

Participated in and managed healthcare management utilization, cost, and quality objectives in accordance with departmental and company goals

Supervised managers, senior care specialists and all other direct reports within HCMS UM

Collaborated with peers to initiate innovative care pilots to improve overall HCMS program

Oversaw the development of policies, procedures and guidelines and ensured information was disseminated to leadership and staff

Supported and participated in quality initiatives and activities including clinical indicators reporting

Identified complex and long length of stay cases and matched to APR DRG payment methodology

Ensured NOMNC were sent in timely manner to agencies and members

Performed and oversaw auditing of the clinical and non-clinical staff

Key participant in reviewing NCQA readiness for look back period

Key participant in streamlining policies, procedures, workflows during HealthPlus acquisition

07/09-9/2010

Lutheran Medical Center

Assistant Director of Appeals

Oversee the denial and appeals process within the Case Management Department

Reviews denial and responds to third party by conducting written standard appeals and expedited appeals when warranted

Assures appeals and responses meet contractual and regulatory obligations

Tracks and trends denial utilizing database

Interprets data and identifies area for process improvement

Educates case managers and consults with physicians regarding denials and criteria

Liaisons with Third Party Payers and QIOs to streamline denial and appeals resolution

Interface with Maximus, CMS and DOI regarding pursuing of External Appeals

Oversees production and distribution of internal reports as requested

Research denial and appeal issues in conjunction with communicating with Patient Accounts, and other departments regarding denials and appeals resolution

11/08-7/09

Tact Medical Staffing:

Assistant Director of Hospital Appeals, at Queens Hospital Center (Temp position)

Assisted in the development of departmental policies, goals, performance improvement projects, presentation and training sessions

Discussed denials with case managers and played an active role in minimizing days denied by assisting with procurement of documentation needed to reverse denial

Liaison with third party agents to ensure timely compliance with review requirements and also provided retrospective clinical reviews when needed

Monitored the timeliness of the certification activities and the submission of the clinical information and assisted with concurrent reviews

Participated in departmental staff orientation and training and developed training materials and provided in-service for staff and physicians based on identified needs

Maintained current knowledge of federal, state and JCAHO guidelines and applied them to activities of the department

Oversaw all third party denial and appeal activities including the external second level appeals

Tracked, monitored, and oversaw the concurrent denials issued by all third party payers including IPRO & RAC and initiated intervention to minimize the days denied

Coordinated responses to third party payers for cases requiring physician’s input and reviewed responses from physicians for appropriateness and adequacy

Communicated with managed care companies to obtain processes in order to streamline workflow and problem solve issues as they arose

Maintained master computerized and manual database of all audit information from initial requests through conclusive determinations

Prepared and submitted weekly, monthly and quarterly trending report by service regarding the number of denials, determinations and DRG analysis

Prepared and submitted quarterly Board reports for all third party denial activities

Coordinated all functions of the UM Committee including the minutes and reports

12/31/07-5/08

Americare CSS Homecare

Director of HMO

Provided clinical and general support to clinical and clerical staff in the delivery of client care

Evaluated the performance of assigned staff in meeting productivity and quality standards

Supervised adherence to established time frame in receiving and completing 485's

Participated in quality assurance activities including formal and informal audits

Contacted the managed care organizations to discuss case concerns, issues, guidelines and timeframes

Ensured that authorizations obtained were data entered in timely manner to help streamline the billing process for patients being seeing in the Adult Homes

Investigated and researched billing/claim payment issues with the managed care companies and the billing department

Verified third party coverage and eligibility via the applicable program such as EMEDNY

Reviewed the denials that were received from HMO's and the appeal information that was submitted to the managed care organizations for reconsideration

7/00 -1/08

HIP of Greater New York

Director of Continuing Care, 6/03-1/08

Performed oversight and management of Assistant Director, Care Managers and clerical union staff

Managed all activities in Home Care, DME services and End-of-Life Program process, including staffing requirements in order to ensure prompt and accurate handling of requests

Oversaw the review of home infusions and enteral cases to ensure medical necessity was being met and that care could be safely provided in the home

Assisted with the preparation and maintenance of approved departmental budget

Developed and maintained policies and procedures within Home Care/DME and End-of-Life subunits to meet State, NCQA, URAC, DOH, DOI, and HIP guidelines

Consistently promoted departmental goals and implementation of activities to meet or exceed strategic plans

Analyzed departmental utilization reports and reported all required data

Maintained effective liaison and working relationships interdepartmentally and with providers, members and regulatory agencies to assure appropriate and timely delivery of service

Assistant Director Pre-Authorization, 7/00 - 6/03

Managed and delegated assignments to a staff of twenty-five nurses

Planned and managed all activities relating to the pre-certification of scheduled surgical procedures and home care processes

Ensured efficient and effective daily operations of the department

Directed orientation of new staff and monitored performance of clinical staff to ensure departmental and organizational goals were met

Performed probationary and annual reviews of staff

4/99 - 6/00

CBB Medical Services

UM/QM Coordinator

Performed concurrent utilization review of all admissions

Conducted daily telephone rounds with physicians and HMO case management

Evaluated appropriateness of acute care service, discharge planning and case management needs

Calculated length of stay for each admission using DRG guidelines and reviewing cases with physicians

Conducted retrospective review of medical records for non authorized services, admissions appropriateness and medical necessity of length of stay

Conducted and documented quality monitor checks for inpatient and outpatient services

Participated in Quality Management committee meetings

Education/Certifications/Memberships:

University of Phoenix Online, BSN

Borough of Manhattan Community College, AAS

PRI Assessor #64236

Certified Case Manager

Certified Managed Care Nurse

Member of Sigma Theta Tau; Member of CMSA

Member of American Association of Managed Care Nurses

Skills/Knowledge:

MS Word, Outlook, Excel, Canopy, Misys, 3M, Navigant CDI Monitor, Altuista, HealthBridge,

Medicare, Medicaid, Aetna, Apollo, Milliman & InterQual Criteria

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