Case Management Registered Nurse
Resume:
Arlyne Gant, MBA, MS, BSN, RN, CCM
**** ********* **. *******, ** 33870
ad5crz@r.postjobfree.com
C: 317-***-****
PROFESSIONAL EXPERIENCE
AMEDYSIS HOSPICE (COMPASSIONATE CARE)
Registered nurse for hospice patients in their homes or facilities. Role includes bereavement counseling, assisting patients and families with coping mechanisms. Educating families, caregivers, and patients regarding disease process, prognosis, and progression.
OPTUM SERVE/LHI
4/25/2022 – 08/08/2022
Medical management and diagnostic evaluations of chronic health conditions for certification of care. Population health members including Veterans, 911 Responders, and 911 survivors.
MINDLANCE/CIGNA
1/14/2022 – 02/14/2022
Case Management/Utilization Management of focused population with chronic illness. Performed risk analysis functions and care management of clinical escalations. Responsible to provide training for providers on disease state management along with behavioral health illness coaching to members.
HFRI/HEALTH CARE FINANCIAL RESOURCES
7/19/2021 – 10/8/2021
Medical Case Manager Consultant for denials and appeals. Liaison for 3 hospital systems in Chicago (Northwestern, University of Illinois, and Lurie Children’s hospital) to administer appeals for all inpatient and outpatient service denials with custom appeal letters. Consulted with providers/clients to insure timeliness and increased denial overturn rate.
SOUTHERN REGIONAL MEDICAL CENTER
12/02/2020 - 01/22/2021
Case Management/Utilization Management Consultant responsible for restructuring department to achieve desired outcomes. Assessment of current Case Management department, hiring of permanent director, process improvement, designing new UM procedures, and assisting current staff through management changes. Staff coaching while assuring proper roles and talent placement. Improving length of stay metric by instituting interdisciplinary rounds and decreasing 30-day readmission rate by setting up a focused readmission prevention program. Decrease avoidable days by improving relationships and communication with physicians. Instruction to staff and physicians in the importance of proper initial patient status in terms of observation vs inpatient status. Reporting of metric goals to executive leadership as well as education and relationship building with the physicians and other department directors.
ADVENT HEALTH
7/22/2019 - 6/5/2020
Accreditation and Process improvement specialist responsible for all survey readiness activities as well as regulatory compliance for all three campuses and 25 medical practices. Performed all survey readiness activities including Joint Commission, State Surveys, CMS inquiries, both announced and unannounced. Conducted onsite inspections to assure compliance with all requirements. Provided onsite education for any findings out of compliance. Performed formal presentations and education for physicians, executive leadership, and department directors. Worked in conjunction with infection control leads to institute all Covid-19 precautions and protocols assuring compliance throughout the organization. Continuous monitoring of quality measures including HEDIS measures.
HEART OF FLORIDA
12/31/2018 - 05/26/2019
Case Management Director responsible for all UM and Care Management functions including, but not limited to, managing all case management staff, the development of UM initiatives and processes that include maintaining a Medicare LOS index of < 1.0 and assuring the Medicare readmission rate is below the national crude rate. Development of the Utilization Management and Quality/PI plan, Leading UM meetings presenting metrics and interventions to executive leadership, physicians, and board members. (Acquired by another hospital system)
HIGHLANDS REGIONAL MEDICAL CENTER
4/1/2015 - 10/31/2018
Director of Case Management responsible for all UM and Care Management functions including, but not limited to, managing all case management staff, the development of UM initiatives and processes to improve metrics and outcomes by initiating an emergency room case management plan, and restructuring collaborative care rounds to include both CDI and Revenue cycle. Decreased Medicare LOS from 5.6 to 4.2 and decreased all payer LOS from 4.6 to 3.76. Developed a readmission prevention program, and served on the Quality, Patient Safety, Compliance, Infection control, and Patient Satisfaction committees. Designed and implemented a hospital wide case management orientation class. Educated leadership, physicians, and staff on reimbursement methodologies including Value Based Purchasing and Bundled payments. Utilized patient and staff engagement techniques such as Motivational Interviewing and Patient Activation Measures to improve performance and achieve positive outcomes.
INDIANA ORTHOPEDIC HOSPITAL
4//2013 - 3/2015
Performed UR, discharge planning, quality improvement, and CDI functions. Managed workers compensation and disability cases. Lead educator for total joint replacement pre-op patient classes. Physician educator for reimbursement principles. Completed MBA practicum working with IT to develop an application/data warehouse that stores analytics, by surgeon, to track key performance indicators.
CONSUMERS’ CHOICE HEALTH INSURANCE COMPANY
9/2012 – 12/2012
Interim Director of Clinical Operations of a start-up health plan in South Carolina for the Affordable Care Act. /Health Care Exchange. Completed NCQA certification, implemented new policies and procedures, completed contract negotiations for medical providers, medical management, TPA, and credentialing services. Created budget for case management and utilization management.
INDIANA UNIVERSITY HEALTH
12//2009 – 8/2012
Manager of Medical Management for Medicare Advantage, Risk Based Medicaid, and IU Health commercial employee plans. Initiated Behavioral Health program, population and disease state management, Total of 110,000 managed care lives. Participated in the startup of ACO initiatives including the establishment of the Medical Home model, placement of case managers at outpatient offices, and contracted skilled nursing facilities. Initiated NP rounding in facilities to assure member’s health needs were being addressed and to identify gaps in care. Development of new internal structure for Behavioral Health integration and direct oversight of 30 FTE’s including RN case managers, MSW’s, care coordinators, and administrative staff. Responsible for URAC certification. Utilized member and staff engagement techniques including education and coaching of motivational interviewing. Implemented a new readmission prevention plan lowering the 30-day readmission rate from 18% to 13% for the Medicare Advantage population and education of new reimbursement methodologies including value based purchasing and bundled payments. Initiated predictive modeling techniques, stratification, and identification of high-risk cases. Implemented new UR and Care Management software. Lead education for staff on utilizing Interqual and Milliman criteria.
CONSECO LONG TERM CARE
10/2007 - 10/2009
Clinical Delegation Oversight Manager for contracted case management vendor. Program manager along with IT for complete EMR platform replacement. Performed oversight management of call center performance and training, Assured compliance with call center metrics including hold times, disconnects, and HIPPA compliance. Performed quality checks by listening to recorded CS calls and crafting changes to messaging. Collaborated with other members of the management team with regards to legal issues, compliance, regulatory, and business practices. Initiated proposal for migration of outsourced case management to an in-house department.
PROGRESSIVE CARE NETWORK (FORMALY INTEGRATED CARE MANAGEMENT)
2/1997 – 3/2007
Chief Operating Officer and Designer of a successful managed care provider network. Created and directed a state-wide provider network for the largest HMO in Indiana. Grew network providers from 7 to 35 providers including Home Health, Home Infusion, DME, and wound care supplies. Worked directly with payer case managers to coordinate discharge planning and post hospital needs. Network management functions included: Credentialing of all providers and performed quality control measures. Obtained NCQA certification, Direct supervision of all staff, conducting performance reviews, and network management education. Lead all marketing and branding initiatives including physician networking, sponsoring of case management conferences, and CMSA involvement. Accountable for all contract negotiations and financials including AR, AP, budget, P&L, billing, provider reimbursement, profitability, and financial integrity. This model design was adopted by Indiana Health Care Alliance in 2006.
CARE AT HOME INDIANA/INTEGRATED CASE MANAGEMENT
11/1995 – 3/2001
Director of Home Health agency with direct supervision of RNs, LPN, s Home Health Aides, PT/OT/ST, and Social Work. Responsibilities included Regulatory Compliance JACHO, State and Medicare certifications and survey readiness. Assurance of correct and timely OASIS submissions. Plan of care (485 s) certification and recertifications reviewed and signed by physician within established time frames. Resolving of staffing issues and performing staff evaluations. Creation of Integrated Care management provider network 2/1997.
CLINICAL NURSING EXPERIENCE
1986 – 1995
Surgical ICU, Open Heart recovery, Emergency department, Medical/Surgical inpatient unit, Adolescent Substance Abuse RN, and Home Health Care.
EDUCATION / LICENSURE / CERTIFICATION
MBA, Healthcare, 2013, Western Governors University, Indianapolis, IN
MS, Counseling 1992, University of Evansville, Evansville, IN
BSN, Nursing, 1986, Indiana University School of Nursing, Indianapolis, IN
Current RN compact License
Current RN Florida License
CCM, Certified Case Manager, 2005-present
PROFESSIONAL AFFILIATIONS /COMMUNITY OUTREACH
Case Management Society of America: Board member and Treasurer of local Indiana chapter
2004-2012
Junior Achievement Instructor 2015-2017
Big Sister program 2016-2018
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