Management Manager
Resume:
Deborah A. Baitinger, RN, CMCN
Detroit, MI 48201
Professional Experience
Automated Benefit Services-Managed Care Administrators (ABS-MCA) 3/12 – Present
ABS is a third party administrator with a 25+ year history of claims adjudication in the Metro Detroit area. MCA is
a start up brought on in 2012 to provide the clinical component of utilization management, disease management and complex case management.
Director Care Management / Clinical Services
Built the care management department, programs and policies in accordance with NCQA standards.
Built all clinical functionality of Medecision Care Management including auto work flow rules, auto approval rules, and Iexchange, a web based physician portal.
Incorporated clinical services into the ABS day to day operations.
Worked with IT to implement Verisk Analytics for commercial and Medicare populations.
Implemented care management functionality of software to the Cayman Island National Insurance Company (CINICO).
Provided direction on clinical activity requirements for CINICO.
Developed standard reporting packages for various clients.
Successfully wrote and submitted application for a local MSSPACO.
Developed the compliance program and all polices for two successful MSSP ACO’s.
Developed programs to support care coordination at the two ACO’s.
Provided leadership with the Quality Committees and Group Practice Reporting Option (GPRO) reporting for the ACO’s.
Developed the GPRO reporting procedure and document.
Wrote and submitted numerous RFP’s relating to self funded business opportunities.
Working with two major hospital systems to build a new physician network
UAW Retiree Medical Benefits Trust 9/10 – 3/12
The VEBA plan for the Big 3 Auto company retirees, managing more than 1 million covered lives.
Senior Manager Population Health
Developed the Senior Manager position.
Responsible for data analysis and program implementation for the UAW retiree population.
Extensive work with national and local health plans.
Established work plans for implementation of new benefits with various health plans.
Provided direction on implementation of new HMO programs including smoking cessation, end of life care, and diabetes education.
Monitored effectiveness and provided analysis of programs.
Provided clinical input on web site development.
Midwest Health Plan 1/08 – 9/10
A Medicaid and Medicare Advantage Health Plan in the State of Michigan
Director Health Services
Responsible for the Health Services Departmental Operations.
Management of 10 staff who review in-patient hospital care, authorize services for out patient care.
Developed a comprehensive case management program meeting all of the required state and NCQA standards.
Responsible for the UM aspects of the McKesson IS project.
Developed a “Preferred Provider Network”. Negotiated contracts with preferred providers.
Developed multiple policies and program documents related to quality and utilization management.
Provided leadership and training relating to appeal and grievances.
Statistical reporting of utilization data.
Provided leadership with the ABW Programs and the Health Choice Program.
Resource person for interpretation of benefits for the ABW and Health Choice Products.
Obtained a score of 100% on file review for both denial and case management files for NCQA.
Developed and implemented the “Green Light Go” authorization grid project – 2009 MAHP Pinnacle Award winner.
Completed a re-design of the entire authorization process.
Fidelis Secure Care 4/06 – 8/07
Fidelis was a start up of a specialized Medicare Advantage Special needs plan dealing only with nursing home bound patients
Director Managed Care Operations
Responsible for set up and maintenance of claims payment procedures resulting in a 100% timely claim turnaround time of less than 30 days.
Reconciliations with Medicare enrollments with accurate outcome of membership roster.
Liaison with TMG Health (TPA) and the CMS regional office.
Presentations to Extended Care Facilities on Medicare Advantage Health Plans.
Directed nation wide staff in medical policy determinations.
Provided leadership and training relating to CMS appeal and grievance requirements.
Statistical reporting of utilization data.
Direct contracting responsibility for physicians, hospitals and nursing homes.
Management of claims and enrollment staff.
Point person for Medicare Audit preparation.
Chairperson of the Credentialing Committee, responsible for oversight of Credentialing process.
DMC HEALTH PLANS 3/98 – 3/06
The Managed Care division of the Detroit Medical Center, responsible for all Managed Care contracts and management of the employee health plan.
Manager Medical Management / Quality Management, Project Manager Continuum of Care Specialist
Quality Management Coordinator
Provided day to day leadership related to the Medical management department composed of 25 data entry personnel, LPNs, and RNs.
Provided support and interpretation of data from the MC 400 computer system.
Created training manual and provided education for multiple departments on the MC 400 computer system.
Developed query reports for Medical and Quality Management; Maintained work queues in MC 400
Provided data for Health Alliance Plan and Blue Care Network for their NCQA Accreditation Process.
Chairperson of the Benefit Interpretation Committee; Involved in overall benefit design for the DMC Employee Health Plan.
Formulated statistical analysis from data provided by multiple health plans contracted with DMC Health Plans.
Developed the graph analysis reported to the board.
Assisted with the coordination of MPRO audits.
Implemented pharmacy utilization reporting and ER usage analysis.
Formulated Clinical Practice Guidelines and Preventive Health Guidelines.
HEALTH ALLIANCE PLAN 1/95 - 3/98
Project Manager Concurrent Review, Managed Care Coordinator
BON SECOURS HOSPITAL 7/76 - 12/94
Registered Nurse; Orthopedics, Preadmission Screening/ Utilization Review Coordinator, Office RN
Computer Skills
Proficient with: McKesson CCMS, Medecision, Aerial Care Management, IExchange, Verisk Analytics, All Microsoft Office Products, various EMR’s
Professional Organizations
Certified Managed Care Nurse - American Association of Managed Care Nurses
Co Chairperson ABSMCA Quality Committee
Chairperson Benefit Interpretation Committee DMC Health Plan
Chairperson Quality Improvement Committee DMC Health Plans
Founding Member / Secretary - American Association of Office Nurses: Great Lakes Chapter
Volunteer Experience
American Red Cross Disaster Volunteer – Health Services Manager responsible for deployment of > 300 health care professionals post hurricane Katrina September 2005
St. Patrick Senior Center, Finance Chairperson & Parish Council President St. Patrick's Church
Education
Harper Hospital School of Nursing Detroit, MI
Siena Heights University
University of Detroit – attended
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