Management Manager

VALARIE B. PHILLIPS, RN

HEALTHCARE EXECUTIVE, SPECIALIZING IN CASE MANAGEMENT MEDICARE POPULATION

CCM® Board-Certified Case Manager

760-***-**** * ac0q67@r.postjobfree.com

WORK OF EXPERIENCE

Roots Healthcare Consulting Firm 09/2013-PRESENT

VP of Clinical Operations Change agent leader and contributor of a team focused on solving nationwide healthcare problems. Responsible for guidance developing solutions and business models within healthcare theatres, (Information Technology, Case Management, Utilization Revenue, Quality and Revenue Cycle Management). Strong strategic planning abilities. Experience managing in a matrix organization. Demonstrated leadership skills which motivate, and inspire colleagues. Leveraged sales experience to drive and close new business. Support companies’ presence at conferences and events. Excellent financial data analytic skills, management and presentation experience. Support member centric development and implementation. Recruit and develop analytical, critical thinker talent to promote client’s agenda. Trustworthy and responsive to organization and client’s needs. Drive continual quality improvement processes throughout organization networks. Evaluate and negotiate contracts. Manage and develop network configuration and incentive-based re-imbursement payment models, Direct and oversee of conflict resolutions. Develop and manage solutions which increase and/or maintain companies competitive edge and brand. Six months to two year contracts with organizations in an upper management capacity to insure direct collaboration with stakeholders, Board of Directors, and C-Suite.

Director of Case Management/Quality/Revenue Cycle Management outsourced as Director of Case Management/Quality/Revenue Cycle Management. Served as Director for period from six months to two years. As Director performed specialist trouble shooting operational problems, research, identification of solutions to fit organization budget, development of program, processes, policies and systems, implementation and management of constructed practice. Authority on accurately constructing, editing, reviewing plans of actions. Development of staff and systems which positively impacted patient centered care planning across the care continuum. Data mining to determine and develop initiatives. Plan and communicate design programs and initiatives that met the mission of the organization. Design performance measures across the organization to assure accreditation, certification, licensure and/or compliance. Organized and act as facilitator in multidisciplinary collaborative processes/programs with community vendors and managed care organizations to promote smooth transitions of care. Oversight of organization/network systems utilization management activities related to Case Management and Discharge Planning. Expertly interpret beneficiary utilization and benefit data ensuring health plan and regulatory requirements/standards are met. Conduct mock surveys, healthcare delivery documentation audits. Expert at root cause analysis.

Director of Case Management Manage Care Environment -Specialized in Care planning Medicare and Medical Population-Direct and coordinate the Medical Management, Case Management and Quality Improvement for the Coordination of Care across the Health Care Continuum. Costs, forecast analysis of operations monitoring the progress toward goals and objectives. Participate in provider education and contract negotiations. Conduct organizational studies, evaluations, design systems and procedures. Develop and prepare operations and procedures manuals. Analyzed, developed and disseminated Case Management and Quality productivity reports. Expertly re-organization and manage care for high risk Medicare & Medicaid business for proficient care delivery challenges related to the Health Care Affordability Act. Recommended strategies to enhance patient engagement, marketing and provider involvement. A key member of the senior leadership team collaborating with the C-Suite staff and regulatory bodies.

Performance Improvement Analyst Consultant-Development, regulatory compliance audits, create operational plans, reports, and dashboards to meet quality improvement objectives. Performing reimbursement audits for Utilization Management and coding compliance. Create clinical and operational policies and procedures in the re-organization of the Case Management, Utilization Review and Quality Improvement areas. Collaborating with physician care providers to assure organization utilization goals as well as documentation goals were achieved. Review, evaluate, analyze patient records to determine care delivery documentation compliant within EBI standards. Train and facilitate staff and physicians in clinical documentation and appeals. Analyze documentation for appropriateness, oversight of Medicare appeals; participated in Revenue Cycle Management strategies. Liaison with primary payers regarding benefit utilization. Prepare for healthcare providers audits and/or accreditations. Developed methods to track and trend appeals for performance measurements.

Sharp Health Care Systems, San Diego, CA. 07/21/2009 to 06/15/2013

(Federally Approved ACO Health Care Pioneer Pilot Provider)

Kara Bourne, Manager 858-***-**** 8695 Spectrum Center Blvd. San Diego, CA 92123

Role & Responsibilities and Length of Experience:

Director of Operations (Regional) 2010-2013 Designed and Managed ACO Pilot Project. Strategic planning and implementation and revision of hospital systems r/t federal and state regulations, oversight of physicians and healthcare system providers to align care delivery, develop technological applications, organizational structure and infrastructure, support Revenue Cycle Management to meet long term and short term goals, draft EBI policy and procedures for a systematic program for the delivery of care based upon federal and state regulations and the Continuum of Care, worked closely with CFO, to establish care coordination within Case Management, Quality Improvement, Utilization Review to establish core principals of Triple Aim Framework as well establish techniques, processes and policies to manage and report clinical appropriateness of care.

Director Case Manager/Utilization Review 2009-2010- Support staff supervision, formulated and drafted job descriptions, hire, and train and managed staff. Created organizational plans and care delivery systems. Develop and enforce policies and procedures on the appeal process.

U.S. Nursing Corp., 05/13/2005 to 11/01/2008

Human Resources 303-***-****; 6501 Fiddler Green Circle, Greenwood Village, CO. 80111

Role & Responsibilities and Length of Experience:

Director Corporate Regional Business Development Oversight of project managers at sites. Audit stakeholder site performance quality, cost, and utilization management. Analyze transactions for waste and/or abuse of federal, state or private payor’s funding, identify underpayments and overpayments. Responsible for regulatory compliance, performance improvement, prepare performance reviews. Accountable for business development activities related to the Continuum of Care Cycle with physician providers, other healthcare facilities, and vendors. Support attainment of profitable growth by using strategic Utilization Review methodologies during concurrent reviews, retro review, denial analysis and reporting, appeals. Lead analysis of market assessment of attractive business opportunities that would enhance reporting and compliance with government and accrediting bodies. Responsible for stakeholder’s strategic alignment. Participated in regional facilitates strategy sessions. Provide senior management strategic recommendations. Maintained and updated industry data related too regional, state, federal developments and trends. Manage, coach and train internal teams. Contracted providers:

Summit Health, Texas, Director of Quality Improvement Patient Services

2007-2008

Project Goal- Improve quality efforts which directly impact compliance,

accreditation, and employ national

and state quality goals into core measures.

Sutter Roseville Medical Center, Director of Utilization 2006-2007

Project goal- second reviewer decrease denials.

Methodist Hospital, Memphis, Tennessee, Director of Utilization 2005-2006

Project Goal- Train case management/utilization staff, coordinate, and

facilitate staff on electronic charting systems such as Cerner, Epic,

concurrent review using InterQual and Milliman, software programs i.e.

Allscript.

Menifee Valley Medical Center, Sun City, CA. 04/24/2002 to 10/30/05

Vera Vercher, ICU Supervisor, 951-***-****; 28400 McCall Blvd. Sun City, CA. 92586.

Role & Responsibilities and Length of Experience:

Director Care Transitions-Home Health Care (Complex Patients)-Developed Home Health Care Program transitioning complex chronic patient from hospital to home. Created Special Home Health model initiative, implemented and monitored. Trained staff in care delivery under the model of care. Applied for certification JACHO and approved.

ICU Charge/ Oversight of Clinical Development- Performed presentations for regulatory agencies. Provided input in development of Case Management and Utilization Review specific documentation. Negotiated yearly budget for clinical area. Developed scope of clinical practice specification as practiced in EBP. Provided leadership related to scope of care and skills in an ICU setting.

PrimeCare Medical Network, IPA 10/15/1997 to 04/15/2002

Wendy Lane, Supervisor, 909-***-****; 3281 E. Guasti Rd. 7th Floor; Ontario CA. 91761.

Role & Responsibilities and Length of Experience:

Director of Patient Care Services Quality Management Oversight of clinical activities In Patient and Out Patient contracted facilities, contract providers and associated vendors. Develop and ensure patient satisfaction. Create and establish policies and procedures for Case Management and Utilization Management, Coding, Billing, and Appeals. Maintained open lines of communication across the continuum. Supported physician practice management in QI, CM and UM initiatives. Managed business and clinical practice network operations. Consultant, liaison for clinical staff, hospitalist, Manage Care Organizations and vendors on contract procurement and execution. Advisor to the Corporate Compliance Officer. Participated in long-range planning care delivery and revenue management, third-party subspecialties.

Jenny Craig Weight Loss Centers of America, Inc. San Diego, CA. 09/23/87 to 06/22/97

Role & Responsibility and Length of Experience:

Vice President of Operations 6years/R.N. 9 years/Director of Franchise 7years/Sales and Health Education Trainer8 years/Customer Relationship Manager 9 years/Health and Safety Compliance Officer

EDUCATION

Diploma Nursing. Webster University, St. Louis, MO.,

AS. Associate Degree Nursing. Mt. Jacinto Community College, Menifee, CA.,

BS. Business Science Management Park University, Parkville MO., 2015

MSN Master Science Nursing Case Management in progress est. graduation 2017

Contact this candidate