Manager Management
Resume:
KIMBERLY R. BLUE
Signal Hill, CA 90755
*********@***.***
CAREER OBJECTIVE: Challenging position in healthcare, utilizing my abilities developed through experience and education, with an opportunity for advancement. QUALIFICATIONS
Educated and experienced in Healthcare Management.
Extremely organized, flexible and dedicated with positive attitude.
Excellent oral and written communication skills.
Experienced in operations, workflow and personnel management.
Innovative problem solving skills
PROFESSIONAL EXPERIENCE
Management/Compliance/Credentialing/UM/Quality/HIM
Responsible for regulatory compliance, reporting and achieving the goals and objectives of the organization.
Developed and implemented Utilization Management (UM) Referral processes for operating efficiency and health plan compliance. This includes annual updates and/or changes in the laws, if applicable.
Monitor, analyze and review the effectiveness and efficiency of existing UM, Quality Management
(QM), Case Management (CM) processes, and workflows to develop strategies and resolution for improving or leveraging operational efficiencies and productivity.
Developed reports on utilization patterns of inpatient, outpatient, Complexist, SNF, homebound services, and compares to national standards for health plan and senior management review.
Developed and maintained dashboards for QM, CM and UM to include the following: Acute Bed days, SNF bed days, Readmission Rates, HCC scores, P4P scores, UM specialist throughput, UM coordinator throughput, Referral throughput, Referral system approval steering.
Implemented an automated UM Denial system.
Served as the point of contact for all health plans (Commercial, Medicare, MediCal, Healthy Families and Healthy Kids).
Responsible for all audits and compliance issues in a managed care setting.
Oversight and management of the Appeals and Grievance process.
Oversight and management of the Healthcare Effectiveness Data and Information Set (HEDIS) process for the medical group.
Oversight and management of the HIM process in a Foundation setting.
Company representative for all industry meetings and presented regular updates of the QM/UM workplans as required by the senior management team and the QM/UM Committees.
Oversight and Prepared reports UM and QM reports for presentation to Board of Directors.
Responsible for completing, preparing and submitting all required reports to the health plan including ICE reports.
Responsible for obtaining and maintained delegation status of UM and QM.
Program Manager for CalOptima and LA Care.
Promotes compliance with all Health Plans and Cal Optima regulatory guidelines involving operational, clinical and organizational activities.
Prepared, coordinated and conducted health plan audits. Kimberly R. Blue Page 2 of 4
Coordinated and facilitated communication between IT, Finance, Provider Relations, Credentialing, Member Services, operations and Healthcare Services Departments to ensure that correct policy interpretation occurs and that appropriate systems are implemented to ensure compliance with Health Plan(s), CalOptima and LA Care standards.
Maintained the content of policies/procedures and coordinated with operations on policy related issues for UM, QM and CM.
Developed policies and procedures to meet changing regulatory needs.
Prepare any Corrective Action Plans (CAPs) as required.
Understands department operations and maintains daily presence in the department during business hours. Provided assistance to team as needed.
Maintained and coordinated culturally and linguistically appropriate services for the organization.
Managed and supervised 60+ employees.
Managed all department projects.
Oversight of the department’s staff day-to-day activities, acts as a resource to Senior Management
Develop and implements policies and procedures consistent with the overall goals and objectives of the organization.
Managed the departments within budgetary constraints
Responsible for all personnel related duties: training, counseling, interview, hiring, and performance appraisals for staff
Primary sources verified provider credentials to meet NCQA and HRSA guidelines.
Achieved and managed a department with National Committee of Quality Assurance (NCQA) CVO accreditation.
Audited internal and external departments for NCQA compliance
Developed policy & procedures and forms for provider credential verification to meet NCQA guidelines.
Improved department workflow to increase productivity.
Managed the work flow/ credentialing process for maximum efficiency while maintaining acceptable production standards.
Provider On-Boarding.
Primary Source Verification of all practitioner’s files
Preparation for Credentialing Committee
Provider Separation processing
Prepare Minutes, Agenda and any items for the Credentialing Committee
Assisted MIS Department in development of a Credentialing Maintenance Program. Supervision
Managed & Supervised 60+ employees.
Supervised 5 employees in public service.
Managed, prioritized and delegated responsibility. Office Skills
Working knowledge of different computer applications:
Microsoft Word
Microsoft Excel
Visio
EPIC
Power Point
Internet
MicroMed
Cactus
EDUCATION
Kimberly R. Blue Page 3 of 4
Bachelor of Science in Health Care Administration
California State University, Long Beach
Graduated, August 1993
EMPLOYMENT HISTORY
Dates Positions Address Contact Person(s)
1/27/2016 to 9/14/2016 Credentialing Specialist
The Children’s Clinic
All’s Well
6167 Bristol Pkwy Ste 440,
Culver City, CA 90230
2/2015 to 4/2015 UM Consultant Adventist Health
1720 East Cesar E Chavez
Avenue, Los Angeles, CA 90033
3/2014 to 10/2014 Director of Managed
Care Services
Gemini Diversified Services
18350 Mount Langley Street
Fountain Valley, CA 92708
Craig Rizzi or Tammy White
1/2012 to 7/2013 Director of Provider
Services
Providence Health and Services
5315 Torrance Blvd.
Torrance, CA `90503
David Zembik
6/04 to 1/2012 VP of Care
Management
Director, HCS
Operations
Program Manager
Healthcare Partners
Talbert Medical Group
1665 Scenic Avenue
Costa Mesa, CA 92626
Human Resources
9/2000 to 6/2004 Credentialing Manager
Pinnacle Health Resources, Inc.
Gateway Medical Group, Inc.
17922 Fitch Avenue
Irvine, CA 92614
Human Resources
4/2000 to 9/2000 Manager of Operations
EMP# 020126
PacifiCare Health System.
5701 Katella Avenue
Cypress, CA 90630
Dwight Law
Human Resources
(900) 555-WORK
www.verify.theworknumber.com
5/1999 to 4/2000 Credentialing
Coordinator
Pinnacle Health Resources, Inc.
Gateway Medical Group, Inc.
17922 Fitch Avenue
Irvine, CA 92614
Cory Rayyes
10/1998 to 5/1999 Department Manager
Department Supervisor
MedPartners, Inc.
501 S. Idaho Street, Suite 100
La Habra, CA 90631
Human Resources
Kit Howard
Kimberly R. Blue Page 4 of 4
Dates Positions Address Contact Person(s)
5000 Airport Plaza Drive
Long Beach, CA
12/1993 to 5/1998 Department Manager
Department Supervisor
Sr. Credentialing
Assistant
Credentialing Assistant
FPA Medical Management, Inc.
AHI Healthcare Systems, Inc.
1501 Hughes Way, 4th Floor
Long Beach, CA 90810
Ailen Takeda Zeidman
Chrsitine Honma
4/1989 to 12/1993 Messenger Clerk Los Angeles Public Library, Vernon Branch
4504 S. Central Avenue
Los Angeles, CA
Mrs. Hortense Woods
10/1992 to 12/1992 Administrative
Internship
Martin Luther King Jr., Hospital
Los Angeles, CA
Preceptor: Randall Foster
Mentor: Mrs. King
Contact this candidate