Manager Customer Service
Resume:
DIANE W. DORAN, RN, CCM
**** **** ***** ****, ******, TX 76248-(925)
RN License Texas, 602891, Expiration January 31, 2012
***********@*****.***
Qualifications Summary
. RN with over 13 years of working in managed care utilization
management/case management and extensive managerial experience.
. Vast knowledge of Federal, State and County insurance benefit plans
( Medi-Cal, Medicare, Medicare HMO, Medicare Risk, Medicare/Medi-Cal
Special Needs Plans, SPD's,Healthy Families, IHSS, MRMIP, Health
Care Initiatives, County Basic Health Care-Indigent Care) as well as
most commercial HMO plans.
. Proficient in use of InterQual, Milliman and Robertson, Apollo, CMS,
and Medicare NCD/LCD standardized criteria as well as Title 22
regulation.
. Extensive knowledge of inpatient case management review.
. Effective communication with providers and members and skilled in
conflict resolution.
. Experienced in working in fast-paced environments that demand strong
organizational, technical and clinical skills.
. Capable of running a dynamic department that encourages teamwork and
excellent customer service.
. Use of Internet, Word, Excel, Lotus Notes, McKesson Quik Link and
can easily learn new systems.
Experience Highlights
CONTRA COSTA HEALTH PLAN, Martinez, CA (2/08-6/11)
AUTHORIZATION DEPARTMENT MANAGER
. Managed a department that entered and processed an average of 1200
authorizations a month from various providers as well as a call
center with an average of 2500 calls a month.
. Trained and supervised 10 health plan authorization representatives
and co-managed 5 Utilization Management RNs/Case Managers with UM
Director.
. Performed employee evaluations, disciplinary actions, as well as
coordinated regular staff meetings and necessary training.
. Monitored and served as clinical support for the UM/Case Management
RNs for prior authorization and inpatient reviews.
. Worked directly with Medical Director, UM Director and CEO to
coordinate and deliver quality care management within the confines
of a managed care setting.
. Prepared Health Plan appeals for provider and member appeals as well
as Medicare appeals that needed to go to the Federal level-Maximus
Federal Services.
. Reviewed medical service requests and DME utilizing specified
criteria, copays and benefit interpretation while also meeting
regulated turn around times.
. Department lead for all pediatric cases and CCS (California
Children's Services) services.
. Negotiated service agreements for non-health plan providers.
. Performed yearly site review audits of two coordinated UM facilities
as well as DHS, DMHC and CMS audits and Corrective Action Plans
(CAP).
. Evaluated medical eligibility for health plan applicants.
. Analyzed and adjudicated claims.
. Voted Manager of the Year, 2010 by Senior Administration.
Contra Costa Health Plan continued
UTILIZATION MANAGEMENT RN/ CASE MANAGER (3/04-2/08)
. Responsible for telephonic concurrent and retrospective review of
health plan patients who were inpatient in community hospitals.
. Discharge planning and coordination of services for patients.
. Weekly patient planning meetings with the medical director and other
case managers.
. Communicated with physicians, case managers, ancillary nursing
services and community services to enable a discharge with the best
possible outcome for the patient.
. Responsible for reviewing and authorizing requested medical services
for the health plan (prior authorization requests).
JOHN MUIR/MT DIABLO HEALTH NETWORK, Walnut Creek, CA (9/97-4/04)
UTILIZATION MANAGEMENT SUPERVISOR
. Started and developed the UM department with 2 other nurses.
. Trained and supervised 12 staff members consisting of RN's and
clerical staff directly responsible for authorizing requested
medical services.
. Negotiated provider contracts and payment stipulations.
. Responsible for receiving and processing appeals for service request
denials from contracted healthplans. Member of the Quality
Management Committee.
NMC HOMECARE, Walnut Creek, CA (2/96-1/97)
CASE MANAGER/INTERMITTENT RN.
. Case Manager for 43 extended care and 5-10 intermittent care
patients; home visits; clinical care.
. Pediatric and senior patients.
VISITING NURSE SERVICE OF LONG BEACH, Long Beach, CA (10/93-4/94)
HOME HEALTH RN.
. Primarily worked with AIDS hospice clients.
CALIF. PRIMARY PHYSICIANS MEDICAL GROUP, Los Angeles, Ca 8/91-
1/93
NURSING SUPERVISOR-SURGICAL SPECIALTIES
BRISTOL PARK MEDICAL GROUP, Santa Ana, CA (6/90-8/91)
ASSISTANT NURSING SUPERVISOR
Education and Certifications
SANTA MONICA COLLEGE, Santa Monica, CA
Associate Degree, Nursing June, 1987
RN LICENSURE Texas, 602891, Expiration January 31, 2012;
California, 415169, Expiration February 28, 2013
CCM CERTIFICATION # 00104235 Expiration October, 2012
CPR CERTIFICATION Expires 10/12
References Furnished upon request
Contact this candidate