Medical Manager
Resume:
Bernice A. Hansen
Modesto, CA 95350
Objective
An opportunity that will allow me to utilize my clinical, organizational and interpersonal skills within the
health care industry.
Skills Profile
• Experience in review for correct Clinical Documentation / Case Management/Discharge
Planning/Concurrent Review/Pre-Authorization Procedures/Development of Care Plans.
• Knowledge of ICD9, CPT and HCPCS codes; Interqual and Milliman criteria; familiar with
Medicare/MediCal regulations/DRG’s and compliance issues.
• Strong analytical, assessment and problem solving skills.
• Consistently perform well under deadline demands; adapt well to new responsibilities and
concepts; strong customer relations skills to project a positive company image.
• Work with integrity as a team player or independently to task completion.
• Strong clinical and customer relation skills to project a positive company image.
Experience
Consulting (Malpractice; Erisa); Volunteer Work; Data Entry 11/2012 to present
Catholic Healthcare West (Dignity Health) 9/02 to
10/12
St. Joseph’s Medical Center and St. Joseph’s Behavioral Center, Stockton, CA
Defense Nurse Auditor – (1/2006 to 10/2012)
• Approximate yearly revenue savings - $500,00.00; Health plan defense claim audits; denial
appeals; claims analysis; concurrent review; patient claim disputes; Medicare reviews;
compliance issues; health plan quality issues; health plan contract issues, i.e. HMO, PPO;
monitor physician documentation and charges of the various hospital departments; assist
coders in evaluating physician documentation.
Mercy Medical Center, Merced, CA
Case Manager – (9/02 to 1/06)
• Consistently maintained acceptable patient length of stay; Case Management/ discharge planning
of inpatients/ concurrent review; authorizations; daily interaction with physicians; nursing and
ancillary personnel; interaction with various health plans, IPA’s and Rehab/ Long Term Facilities;
family meetings.
• Peer review screening; assisted with development and implementation of various protocols;
compliance issues.
Valley Physician’s IPA 7/01 to
9/02
Modesto,CA
Quality Manager
• Participated in a successful NCQA accreditation; Health plan audits; medical staff meetings;
physician office site visits; interaction with health plan personnel; appeals; resolution of patient
and physician grievances; peer review screening; QA studies; claims review (ER, OP, and IP);
monitor physician documentation for correct coding; divestiture of the IPA.
Page two – Bernice A. Hansen
Sutter Gould Medical Foundation 4/00 to 7/01
Modesto, CA
Quality Manager
• Participated in a successful Association of Ambulatory Accreditation survey; day to day
operations of the Quality Management Department; health plan audits; medical staff meetings;
budget planning; appeals; daily interaction with third-party payers; QA studies; organizing,
directing and evaluating services of the staff and resolving patient grievances.
• Coding education for physicians, physician office site visits for credentialing, HEDIS
collection, Safety Committee, Infection Control Committee.
MedPartners Provider Network, Inc. 2/94 to 4/00
Northern California Corporate Office, Inc.
Stockton, CA
Utilization Manager, Northern California Region – (9/97 to 4/00 promoted from previous position)
• Day to day operations of the Northern Region Utilization Department to include the divestiture of
the company from Northern California with management and lay-offs of staff of forty (40);
staffing and education of personnel; physician coding education.
• Participated in health plan audits; medical staff meetings; developed policies and procedures;
analyzed physician utilization patterns; participated in a successful NCQA Survey.
• Case management of high risk patients; pre-certifications, concurrent review, follow –up of
denials and appeals; interaction with health plans.
Regional Quality Specialist (2/94 to 9/97 – promoted to above position)
• Performed peer review; physician office site audits; medical record audits; HEDIS collection:
developed audit tools, follow-up of denials and appeals.
• Health plan audits; medical staff meetings; malpractice investigations and compilation of legal
reports; reviewed potential risk management incidents/ possible sentinel events.
Valley Heart Associates, Inc 9/92 to 2/94
Modesto, CA
Director of Clinical Services
• Responsible for staff and physician scheduling; staff education; staff evaluations and counseling.
managed staff of twenty; patient care/ clinical functions; medical staff meetings.
• Responsible for patient satisfaction; QA monitoring; monitoring physician coding .
• Budget and costs responsibilities; ordering of medical supplies and pharmaceuticals.
Doctors Medical Center 7/72 to
9/92
Modesto, CA
• Director of Quality/ Risk Management
• QA/ Utilization Department Manager
• Utilization Coordinator
• Night ER Charge Nurse (Mobile Intensive Care Nurse) and Night House Supervisor
Licensure
• California - 106625
Page three
Affiliations
• California Association for Healthcare Quality
Education
• Monmouth Junior College, Long Branch, New Jersey
• Ann May School of Nursing, Jersey Shore Medical Center, Neptune, New Jersey (Nursing school
has closed.)
• Modesto Junior College – Business Courses
• Hospice Volunteer Training; Dale Carnegie Classes
• Clinical Documentation Training
• Excel
Contact this candidate