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Registered Nurse Manager

Location:
7305, United States
Posted:
March 01, 2011

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******* **************

* ********* **. ****** ****, NJ 07305•201-***-****•***************@*****.***

Profile

Nursing professional with extensive experience in quality improvement in a managed care organization. Broad

scope of responsibility includes regulatory compliance, strategic planning, staff management and project

management. Demonstrated successful operations specific to HEDIS reporting. Proven in-depth knowledge of

continuous quality improvement processes and recognized as a subject matter expert in clinical standards that

drives organizational best practices.

P rofessional Experience

June 2008 to Dec 2010

Healthfirst New York, NY

Director, Quality Improvement PHSP

Responsible for the development, implementation, coordination, monitoring and oversight of clinical

quality improvement programs for the PHSP line of business (Medicaid, CHP, FHP).

Directed annual HEDIS operations, specifically the medical record review process and final reporting

of the rates. Ensured integrity of data while maximizing submissions.

Ensured compliance with regulatory requirements. Participated in audits as part of contractual

obligations with the federal, state, city and external peer review agencies. Responded to Quality Matrix

and Corrective Action Plans. Prepared annual work plan and reported annual program evaluation.

Submitted required clinical focused studies.

Actively participated and reported in quality committee meetings and board meetings. Advised

committees on current standards and clinical practice guidelines.

Assisted in the development and implementation of policies and procedures related to QI programs.

Oct 2005 to June 2008

Senior Manager, Clinical Quality

Spearheaded series of QI initiatives designed to improve quality scores. Instrumental in transforming

the company and turning into one of the leading health plans based on quality performance indicators.

Introduced process improvements and created metrics to maximize productivity.

Provide leadership to staff and hold full management responsibility. Recruited, trained and mentored

staff to achieve full potential.

Oct 2001 to Oct 2005

QI Clinical Manager

Conceptualized and launched QI programs to assigned clinical measures in an effort to turnaround

declining HEDIS rates. The multi-faceted interventions resulted in an increase in rates from below

statewide average to at least statewide average within two years of implementation. Ensured sustained

improvements by ongoing measurement, tracking and trending of statistical data.

Conducted medical record reviews, abstraction and data entry into QI specific software for HEDIS

reporting in accordance with HIPAA regulations.

Developed and implemented strategies to improve provider and member compliance with the clinical

quality measures.

Aug 2000 to Oct 2001

RN Case Manager

Coordinated with the multidisciplinary healthcare team to ensure service delivery through an integrated

case management approach with utilization review and case management activities. Developed patient-

focused care and managed the process across the continuum of care episodes.

Authorized request for admissions and vendor services using clinically proven criteria to make

consistent care decisions. Use of industry standards and benefit plan design, clinical knowledge and

critical thinking to administer cost efficient covered services.

Assisted with discharge planning and care coordination to ensure optimal outcomes.

1998 - 2000

Local 32BJ Health Fund New York, NY

Physician Referral Service Nurse

Assisted union members in finding the appropriate physician that best meets their medical needs based

on their selected geographic area. Ensured that members are connected with the physician's office and

facilitated securing an appointment. Educated the members regarding their benefit coverage to assist

them in making informed health care decisions.

1996 - 1998

Jersey City Medical Center Jersey City, NJ

Staff Nurse

Provided direct care to patients in the Postpartum and Nursery Unit through application of the nursing

process in accordance with approved standards. Delivered a complete range of services from admission

to discharge in collaboration with members of the healthcare team. Performed patient assessments,

assisted physicians with treatments and procedures, initiated and maintained intravenous therapy,

administered medications and monitored patient status. Coordinates discharge planning and provided

patient teaching, counseling and health education.

1994 - 1996

United Staffing Agency Elmhurst, NY

Per Diem Nurse

Assigned at various ambulatory care facilities and outpatient department in the hospitals. Provided

triage, direct patient care and referrals to appropriate providers. Managed multispecialty clinics that

include Urgent Care, Internal Medicine, OB/GYN, Pediatrics, Ophthalmology, Cardiology, Surgery,

Urology, Pulmonary, ENT and Endocrinology. Maintained and organized patient medical records.

Education

1989-1993

Manila Central University Manila, Philippines

Bachelor of Science in Nursing

2003-2005 New Jersey City University Jersey City, New Jersey

Completed coursework towards Masters in Healthcare Administration

Licensure

Registered Nurse Licenses: California – License# 699623 Exp. 10/12; New Jersey – License# 26NR08615900

Exp. 5/12; New York – License# 461024 Exp. 8/11



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