Karen L. Hammons, RN, BSN, MSA, CCM, CCP

248-***-****

PROFESSIONAL EXPERIENCE:

May 2017 Independent Case Management Consultant – West Bloomfield MI

Over twenty years of successful case management experience

Including team development which resulted in 100% of team members

Obtaining case management certification over a eighteen month period,

Program Development, HROB, Early Notification of Pregnancy, NICU

Aversion, CHF, Transitional Care and Pediatric Asthma Programs

2016-2017 Director of MI Health Link Program, Detroit Area Agency on Aging Detroit

Oversight of 45 member clinical and non-clinical staff. Responsibilities

Partner with 5 major Integrated Care Organizations and provided the

Following case management services. Assessments, Care Planning, and

Service and Resource allocation, collaboration with physicians and

assuring compliance with the 3 Way Contract.

2011 – 2016

Director, Clinical Health Services, CoventryCares of Michigan, Inc. Detroit, MI – acquired by Aetna in 2015

Work closely with the medical director in program development and the monitoring of bed days. Communicate with members of the provider community to resolve identified issues and respond to questions related to our departmental processes. Provide oversight of department programs and evaluate effectiveness as well as modify program when needed on a regular basis. Member of various committees, including, Physician Advisory Committee, Quality Improvement Committee, and an active member of the Monthly Operations meetings, (designed to discuss issues related to utilization including prior authorization activities). Responsible for providing leadership, monitoring department performance via regular team member audits, providing training and promoting staff development. 100% of the nurse case managers have their CCM, many of them obtained their certification under my direction. Maintain department compliance by ascertaining programs are aligned with state and other regulatory bodies requirements. Responsible for meeting NCQA standards.

2015 - Aetna acquisition – Additional Responsibilities - Oversight of the Duals Demonstration:

Oversight of 42 member clinical and non-clinical staff in two locations

Integration with the PIHP and ICO oversight

Program development, compliance and analyst

Assure timelines are being met for level one and level two assessments

Ascertain compliance with State/CMS/ICO three way contract

2010 – 2011

2009 - 2010

Director, Complex Case Management, Care Guide (Vendor for Blue Cross Blue Shield) Detroit MI

Responsible for providing oversight of a 45 member multiple discipline case management teams for BCBSM public school retirees. Responsible for writing policies and procedures, weekly reporting to the company CEO, monthly status reports and chart review with BCBSM senior leadership team. Ascertaining program compliance related to timeliness in obtaining member assessment, care planning, and ongoing member contact. Responsible for maintaining URAC program requirements and solely responsible for CM site review which resulted in a successful outcome.

Manager, Case Management, Peach State Health Plan, (Centene), Smyrna, GA

NCQA accredited health plan. Managed and provided oversight and development of a 21 multi discipline HROB case management team. Implemented POD team approach, (POD’s including CMA, MSW and 2 Case Managers) to manage identified alpha split members. Reassigned staff to assure appropriate staff were reaching out to members and working within their skill set, program development, including the writing of policies and procedures, mentoring and regular training sessions, including 1:1 training with identified team members. Facilitated weekly collaborative rounds. Encouraged and assisted with team members obtaining their CCM credential. Responsible for the hiring, staff reviews and termination of staff. Represented the health plan at the state as well as with resolving issues with the provider community. Maintain department compliance by ascertaining programs are aligned with state and other regulatory bodies requirements. Active participant on the Community Outreach team.

2007 - 2009

Manager, Health Services, OmniCare Health Plan, Detroit, MI

Managed and provided oversight of the nurse case manager team. Program development, including writing policies and procedures, implemented weekly collaborative rounds with the UM staff, (Joint Active Management (JAM sessions), where team members, including the medical director discussed barriers to discharge and developed an appropriate and proactive discharge plan. Provided staff development, discipline and partnered with a neighborhood school to provide school based asthma education to faculty, parents and students on site at the school. Lead and directed the work of others; utilized extensive problem solving and decision making. Hiring and training; provided ongoing mentoring, clinical knowledge to ensure that NCQA standards and Medicaid guidelines were followed.

2002 – 2005

Adjunct Professor, Human Anatomy and Physiology, Central Michigan, (Southfield and Troy locations)

Taught anatomy and physiology to allied health students off .

Campus. Ranked 3.3 on a scale of 4.0 by student survey.

1999 – 2007

Supervisor, Complex Case Management, Blue Care Network, Southfield, Michigan

Supervised a 12 member commercial complex case management team. Responsible for oversight of the day to day operations, ascertaining defined timeframes and process were in compliance, assist with monitoring case notes and ascertaining documentation remains in compliance with NCQA and company process guidelines. Responsible for staff development, advocacy, interviewing of potential new hires and the disciplinary process when indicated.

1997 – 1999 Appeals Manager/Co-Director of Utilization Management Dept.

Oakwood Hospital Dearborn MI

Responsible for responding to insurance denials by reviewing the medical record and applying Intequal criteria to my written appeal response. Responsible for representing hospital at ALJ hearing with a 75% success rate in overturning third party payer denials. Oversight of 13 member appeals team. Served as co-director in the department for an interim period when the director resigned. Responsible for staff recruitment, interviewing hiring and firing when indicated. Worked with human resources to perform a market salary analysis which resulted in staff salary increases.

1989 –1997 Discharge Planner/OB Case Manager, Wellness Plan - Det. MI

Position entailed on site utilization and discharge planning for members hospitalized at Hutzel Hospital. Responsibilities included review of hospitalization with rounding physician to ascertain continued hospitalization was warranted, utilizing Interqual criteria, communicating with members during hospitalization to develop an appropriate discharge plan. Ordering DME, home nursing including home infusion, consulting with the hospital discharge planning and providing transportation when warranted. Later transitioned to an in office HROB case manager, member telephonic outreach and program engagement, conduct assessments, develop member centric care planning, provider collaboration and intervention specific to meet member goals.

1987 – 1989 UM/QA Coordinator, Detroit Riverview Hospital – Detroit MI

Utilizing Interqual criteria provided on site utilization and quality review for hospitalized patients. Participated in daily reviews with the physician reviewer and provided quality issues to the Quality department for further evaluation and management.

1985 - 1987 Professional Facility Analysis, BCBSM – Detroit MI

Utilizing Milman and Roberts criteria provide telephonic utilization review for members during their hospitalization and referred those that did not meet criteria to the medical director for further review and peer to peer discussion

1981 – 1985 Staff Nurse, Hutzel Hospital (NICU) – Detroit MI

Provided nursing care to the premature and sick neonate. Duties included vent care, enteral feeding, UAC/UVC line maintenance, medication administration and parent education. (remained on staff beyond 1985 in a contingency basis beyond 1989)

1977 – 1981 Nurse Tech – RN, Staff Nurse, Sinai Hospital, Detroit, MI

Primary duties included providing nursing care to infants in the newborn nursery, medication administration, blood draws and assisting new mothers with breast feeding.

EDUCATION

Central Michigan University, Dearborn, MI

Master of Science in Administration: December 2001

University of Detroit Mercy, Detroit MI.

Bachelor of Science in Nursing: May 1987

Highland Park Community College, Highland Park MI

Associates Degree Nursing - 1978

SKILLS

Excellent engagement skills, skilled in motivational interviewing, good team builder and motivator. Ability to problem solve by providing a win/win outcome. Creative and innovative problem solver. Identified in the top 10% of leaders worldwide by GALLUP UNIVERSITY

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