Care Management

**** ********* ****, **** ******* IL ***** 620-***-**** ***********@*****.***

Rahab Kiarie, RN BSN. MBA

Objective:

To utilize my clinical and supervisory skills to be a better nurse manager and to work for an organization that can utilize my expertise.

Skills:

Knowledge of Managed Care Organization with emphasizes in the Medicaid population

Leading team meetings

Auditing files

Collaboration with other departments to solve problems

Reimbursement Specialist – Experience in care plans, Medicaid and Medicare.

Clinical supervision as interim charge nurse

Member assessment and treatment.

Knowledge of state and Federal regulations

Medical records compliance – Helping with chart audits, utilization reviews, QA processes and assessment of member condition and retention.

Care Management – Focus on chronic disease management and preventative care.

Knowledge of ICD-9, CPT coding and HCPC.

Transitional care from one level of care to the next.

Critical thinking skills and certification of ACLS and CPR.

Experience and knowledge of Interdisciplinary care teams

Professional Experiences:

Molina Healthcare of Illinois, (managed care organization)

Supervisor case management from May 2013 to Current.

Provides case management services to members in Medicaid, duals (Medicaid and Medicare) and those on the exchange that have chronic or complex medical conditions. With an objective of reducing cost through preventing readmission to the hospital and cutting back on the frequency to the emergency room.

Proactively identifies members that may qualify for potential case management services.

Conducts assessment of member needs by collecting in-depth information from Molina's information system, the member, member's family/caregiver, hospital staff, physicians and other providers.

Identifies, assesses and manages members per established criteria.

Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals to address the member needs.

Performs ongoing monitoring of the plan of care to evaluate effectiveness.

Documents care plan progress in Molina's information system.

Evaluates effectiveness of the care plan and modifies as appropriate to reach optimal outcomes.

Adhering to URAC, NCQA, State Department of Insurance and/or standards and accreditation processes of comparable regulatory bodies, i.e. JCAHO.

Interacting with numerous internal departments in ICT rounds and keeps abreast of products and service deliverables.

Accomplishments in role

Reducing readmissions and ED visits to my assigned members

Being proficient in Medicaid and Medicare within the first six months.

Guiding and mentorship of other case managers.

Promoting teamwork and effective work relationships with coworkers, providers and members.

Developing and updating care plans

Help my members navigate through their healthcare system.

Analysis if waiver services are appropriate for members to improve my member’s quality of care and wellbeing.

Select hospital (Long Term Acute Care), Wichita Kansas (June 2009- Dec 2012)

Staff nurse

Assessing patient status and notifying physicians of clinical changes.

Most patients have been through some sort of trauma hence having multiple wounds, dressing of wounds and monitoring their condition and any drainage.

Communicating with patients and making sure that their needs have been met despite having an airway.

Maintaining airway.

Responded in all rapid respond call and code blue situations.

Helping patients transition from being in a hospital bed especially ICU to a step down unit that is acute, at the same time helping patients get ready for rehabilitation or nursing home for more care when stable. Such transitions are accomplished by trying to wean patients off the vents, encouraging independence, Encouraging use of oral medication instead of IV medication.

Advocating for patient rights and notifying the ethical team if need be.

Accomplishments in my role

Mentorship of other nurses

Rapid respond team member

Developed and implementation individual patient care plans.

Accountability, delegation and following up of care to non-licensed staff.

Conflict resolution between patients or family members.

Help with discharge planning and patient education.

Preferred health systems a branch of Coventry insurance. (Complex case manager from June 2011- August 2012)

Assessment of health and psychosocial needs and development of care plans.

Planning with all stake holders to maximize healthcare responses, quality and cost effective outcomes

Empowering the patient to problem solve by exploring care options and alternative plans when necessary to achieve desired outcome.

Encouraging the appropriate use of healthcare services and striving to improve quality of care and maintain cost effectiveness on a case to case basis

Perform concurrent review in accordance to Coventry’s criteria, discharge planning and identifying and identifying alternate treatment programs that provide medically necessary potentially cost effective services.

Early identification and assessment of members for admission to case management program.

Experience and knowledge of managed care products, e.g. PPO, HMO, and POS and billing aspect.

Accomplishments

Proficiency in commercial insurance guidelines.

Steady climb in case load management up to 100 by six months of hire.

Reduction of ED visit and admissions in members.

Disease management for various populations and various diagnoses for example mothers with high risk pregnancies and cancer/transplant members.

Concurrent review for skilled members and inpatient rehabilitation members.

Collaborated with pharmaceuticals company case managers to find programs that would help members cover for services not otherwise covered by member’s insurance.

Telemetry Nurse, interim charge nurse: Wesley medical center, Wichita Kansas (Jan 2008- Jan 2010)

Assessing patients with cardiac and other health problems, trending and monitoring any changes.

Implement patient care for up to 8 patients per section.

Schedule patient admissions and discharges

Interaction with department heads regarding patient care.

Maintaining patient charts and confidential reports

Allocating new admission and delegating patient assignments.

Educated patient/families on health care needs, condition and options.

Accomplishments in my role

Promoted to interim charge nurse within 6 months

Improved support service level by ensuring adequate non licensed staff coverage on the floor.

Evaluation of appropriateness of care plans and physician orders.

Supervising clinical and non-clinical staff

Coaching of other nurses

Thorough documentation of grievances and codes per the organizations policy.

Other experiences:

Currently volunteering in blood pressure screenings at Willow Creek Church.

Participated in Kenya’s National Campaign against Polio.

Participated in community blood sugar and blood pressure clinics during my nursing school days.

Drive through flu shot injections in Emporia Kansas that had been organized by the local hospital.

Participated in Relay for Life in an effort to raise funds for cancer victims.

Awards: Roy and Nellie M Crawford Scholarship, 2006.

Otho and Gertrude Behymer Scholarship, 2004

Roy and Nellie M Crawford Scholarship, 2006.

Education:

Master’s in business administration (Dec, 2010)

Newman University

Bachelor of Science, nursing (May 2007)

Emporia State University, Emporia Kansas

Professional references available upon request.

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