Manager Health

KATHLEEN D. HERRIGES

314-***-**** • ac0lq3@r.postjobfree.com

SUMMARY

Care Manager with extensive experience in Utilization / Discharge Planning in the acute hospital setting. Familiarity with payer sources including MediCare, MediCal, MSI (Medical Services for the Indigent), commercial insurances and non-funded individuals. Utilization review proficiency with Milliman / InterQual criteria guidelines. Proficiency in facilitating acute and non-acute transfers. Key strengths include Utilization and Case Management experience, enhancing work processes and quality to provide clear communication of clinical information to facilitate Health Plan approvals and denial avoidance. Proven leadership ability with experience in managing complex multi-functional projects. The latest project involves Utilization Department process enhancements at Seattle Children’s Hospital.

PROFESSIONAL EXPERIENCE

HCPro Clinical Documentation Improvement Specialist boot camp training and orientation – St. Luke’s Hospital April 2016-October 2016

Seattle Children’s Hospital, Seattle Washington January 21, 2014 – February 2016

Seattle Children’s Hospital (SCH) is a 254 bed specialty Children’s hospital that serves the pediatric population in Alaska, Idaho, Montana and Washington.

RN Utilization Review (UR) Nurse

The UR RN position includes fulfilling hospital Utilization Management policies and procedures by performing review of scheduled and unscheduled patient admission, continued stay review and discharge planning for appropriate level of care classification. Proficient application of Pediatric Interqual criteria throughout the continuum of care. Seamless team-work with health care team to resolve classification and denial issues.

Developed Admission/Continued/Observation stay review templates to assist non-clinical UR staff in writing clinical reviews. This process lessened Health Plan denials from 300 to 100 denials for the Appeals Coordinator.

Developed verbal process to facilitate secondary review process.

Initiated and developed work-groups on a regular basis that served to mentor and provide education to the non-clinical staff.

Developed positive professional relationships with outside nurse reviewers. This allowed for immediate verbal review that lead to approved days.

Facilitated completion and accurate documentation of hospital standard classifications.

Clinical expertise with review for cases where criteria sets do not apply. Examples include Immunology and medically complex children.

Immediate escalation of cases that involved Health Plan issues negatively impacting payment.

Initiated participation of the UR team in Grand Rounds.

Active partnership with hospital-based Care Coordinators to advise of cases not meeting criteria and assist with Health Plans in facilitating safe discharges.

Integral in developing extended-stay review process to meet compliance objective for long-stay admission.

UnitedHealthCare, Seattle Washington June 10, 2013 – January 17, 2014

UnitedHealthCare (UHC) Community & State is a Lead entity in Seattle WA. Community and State administers Medicaid for its Managed Care Organization (MCO) and Fee for Service (FFS) population. UHC contracts with the state of Washington Health Care Authority (HCA) for administration of the MCO/FFS and Health Home program.

RN Care Manager, Health Home

Supervise and provide oversight of the Coordinated Care Organizations (CCOs) contracted with UHC to provide Health Home services.

Train Care Coordinators on use of Community Care Platform.

Oversight of CCO Health Home activities to ensure program fidelity.

Routine communication with the HCA to report program progress and follow HCA regulatory standards. Monthly and quarterly reports include data-outcomes with enrollment and engagement. Successes and barriers are also reported.

On-site CCO visits to provide Health Home and Platform trainings as contracts are signed and new staff are on-boarded.

On-going communication with GSI the technical web-site developers to assist with trouble-shooting and web design issues.

Project leader in developing Platform modifications to meet regulatory Health Home guidelines.

Consistent/daily communication to UHC leadership regarding program barriers and successes.

Monthly Joint Operations Committee meetings to review outcomes.

Outcomes management according to the six core Health Home services.

Proven positive management of matrix reporting to both National and Health Plan leadership.

Mission Hospital, Mission Viejo California September 28, 2009 – March 14, 2013

Mission Hospital is a community not-for-profit acute trauma center in southern Orange County. The hospital has 407 beds between two campus sites. The main campus is in Mission Viejo specializing in Emergency Services, Neurology, Cardiac, Trauma, Orthopedic, general medical-surgical, ARU, Obstetrics, NICU/PICU and Pediatrics. The Laguna Beach campus is where behavioral health and addiction medicine are located along with a small ICU and Medical/Surgical unit. Patients are transferred between campus’s depending on specialty and services required.

Care Manager

Performed discharge planning and utilization review daily on all specialty units.

Timely intervention with patient and family to meet post acute clinical care needs and appropriate level of care. Discharge begins on day of admission.

Successfully travelled between all units and sites to perform Care Management intervention.

Excellent collaboration with multidisciplinary team.

Proficient verbal and written communication skills.

Utilization Review expertise includes Milliman/InterQual criteria. Allscripts/ECIN program for UR and MediTech electronic medical record.

Adherence to regulatory requirements such as TARS, transfer documents, CCS referrals, TB discharge forms, MediCare letters, Observation status.

Managed acute transfers.

Review of potential incoming transfers and appropriateness of care and payment.

Hospice coordination.

From 2005 to 2009, accompanied spouse on international corporate assignment in Mexico.

LA CARE HEALTH PLAN, Los Angeles, California Oversight Specialist 08/2003 – 04/2005

HMO with population of approximately 800,000 members. Product lines include MediCal, Healthy Families, Healthy Kids, CalKids and In Home Special Services (IHSS). LA Care delivers Managed Care services to the underserved population in Los Angeles County.

Oversight Specialist

Utilization Management Oversight nurse for the Participating Physician Groups (PPG). Perform annual Utilization Management audits, continuous monitoring activities, focus studies, audit tool creation and design.

Developed an enhanced Utilization Management Oversight Program by creating a user-friendly audit tool.

Facilitated Utilization compliance with the Utilization Management process with the Fee-For-Service groups by performing Utilization Management training.

Enhanced communication regarding the audit process by creating a file review spreadsheet that is readable and mathematically correct.

Achieved greater PPG compliance with Utilization Management standards by facilitating open communication through on-site visits, written and oral communication.

EL PASO FIRST HEALTH NETWORK, El Paso, Texas. Health Services Manager 02/2000 – 05/2003

HMO with population of 44,000 members specializing in Medicaid, CHIP and Indigent Managed Care health delivery model.

Health Services Manager (2001-2003)

Managed all aspects of the Health Services department, including Case Management activities, the appeals process, set-up of system, claims review, procedure and policy development, and tracking and trending of key indicators and statistical data. Managed seven full time employees, four clinical staff, and three non-clinical positions.

Grew prenatal membership from 67 members to 930 members and increased revenue by $2.6 million dollars through the initiation of a dynamic prenatal program.

Implemented immunization program resulting in 700 children gaining access to health care and being current with immunization status as per HEDIS measure.

Improved number of members participating in asthma/diabetes disease management program by 75% resulting in a proactive asthma/diabetes management by our members and decreased inpatient admissions.

Secured cost savings of $2 million for Thomason Hospital by re-negotiation of outsourcing cardiac contract.

Identified $25,000 in cost savings in a five-month period for Thomason Hospital by managing indigent home care and DME services.

Achieved HIPAA compliance within health services by establishing HIPAA policies and procedures as of April 14, 2003.

Developed efficient work processes by utilizing quality improvement processes without addition of new employees.

Developed Utilization/Case Management claims mapping on April 1, 2003 by supervising Utilization Management (UM) and Case Management (CM) staff, including selection, orientation, training, development, and performance management.

Improved asthma management for CHIP population by development and initiation of asthma education program.

Performed at 100% compliance for delegated services of behavioral health, vision and pharmacy entities by ongoing monitoring and oversight.

Registered Nurse Case Manager (2000 – 2001)

Managed Medicaid, Community Voices, and Children’s Health Insurance Program (CHIP) accounts, performing prospective, concurrent and retrospective reviews using tools established by NCQA standards, contract requirements and the Texas Department of Insurance requirements.

Proficient in use of Medicaid guidelines, Milliman and Robertson, and InterQual criteria sets, ICD-9-CM, and Multiplan directories with resultant quality review processes.

Implemented use of proactive case management methods by managing high risk, catastrophic, transplant, disease management and other high cost cases.

Collaborated with community providers to teach and communicate the methods of Managed Care principles.

ADDITIONAL PROFESSIONAL EXPERIENCE

LA Care Health Plan Oversight Specialist (08/2003 – 04/2005)

From 2005-2009 accompanied husband on International assignment.

El Paso First Health Network Health Services Manager (02/2000-05/2003)

CORE INC., RN Case Manager (1994-1999)

HUTCHINSON TECHNICAL COLLEGE, NURSING INSTRUCTOR (1990-1993)

MEEKER COUNTY HOSPITAL, Staff Nurse and House Supervisor (1989-1990)

MISSION COMMUNITY HOSPITAL, Staff Nurse (1988)

CHILDREN'S HOSPITAL OF ORANGE COUNTY, Pediatric Oncology Staff Nurse (1987)

MISSION COMMUNITY HOSPITAL, Staff Nurse (1986-1987)

GROUP HEALTH INC. Assistant Nursing Supervisor, Head Nurse Urgent Care (1982-1985)

UNION HOSPITAL, Pediatric Staff Nurse (1978-1982)

UNIVERSITY OF MINNESOTA HOSPITAL, Staff Nurse (1976-1977)

EDUCATION

B.S., Health Care Services, University of Phoenix (February 2004)

CERTIFICATIONS

Registered Nurse with National Certification in Case Management

Certified Case Management Registration Number M-025471

California # RN 395335 (active)

Missouri #RN 201-***-**** (active)

Certified Washington Health Care Authority Health Home Trainer

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