Management Medical

Carol Slipman RN, BSN, CCM, LNC

*** ********** ******, ********* *** York 11572

Phone: 516-***-****

Email: **********@***.***

Experience Summary:

Dedicated highly skilled professional with more than ten years in the healthcare environment offering exceptional experience in Managed Care with a working knowledge of Utilization Management, Care Management and Complex Care philosophies.

Experience:

MetroPlus Health Plan-New York, NY 3/2014-Present

Associate Director of Nursing

Supervise staff and participate in the day-to-day activities and evaluation of utilization/care management for inpatient admissions to a skilled nursing facility, long term custodial care facility, acute rehabilitation facility, and home health care services.

Promote and facilitate a multidisciplinary approach to coordination of care and discharge planning for managing the member’s health and wellness.

Initiate the timely and accurate information into the Health Commerce System for completion of the UAS. Ensure staff has an understanding of the assessment scores related to the member’s physical, mental and emotional needs as it pertains to Long term custodial care in a facility or Personal Care Services at home.

Conduct utilization review audits and quality of care monitoring activities to maintain staff competency.

Work with staff to ensure compliance with all Federal, state and local regulations and regulatory mandates within established time frames.

Serve as a clinical resource/educator.

Investigation and resolution of clinical claims related issues.

Healthfirst- New York, NY 5/2006-8/2013

Assistant Vice President, Medical Management 10/2011-8/2013

Provided leadership for all clinical, administrative and policy functions of comprehensive Care Management and Utilization Review in the Medical Management Department.

Developed a Transitional Care Program for dual eligible members that provided a smooth transition to the next level of care from the hospital.

Designed and implementated an Institutional-Special Needs Plan, Medicare Advantage Plan for members who resided in a long term care facility in order to maintain their health and wellness.

Participated in the development and process flows for several new lines of businesses including a Medicaid Advantage Plus program which includes MLTC benefits, a Fully Integrated Duals Advantage (FIDA) Program and the Exchange/Qualified Health Program.

Initiated a Short Stay Medical Necessity Review Program to identify conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.

Improved the efficiency within clinical operations by supporting new system workflows

Represented the organization at professional conferences.

Director Medical Management 12/2009-10/2011

Provided leadership and direction for Utilization/Case Management staff.

Planned, monitored and or managed the budget within the department.

Monitored and managed Healthfirst’s Delegated vendors.

Developed and updated all Medical Management policies and procedures.

Assistant Director Medical Management 10/2008-11/2009

Provided leadership and direction for Utilization/Case Management staff maximizing the quality of member care and effectively managing available medical resources.

Developed positive relationships with owner hospitals and nursing homes to effectuate timely transfers of members to network hospitals and or members to other care settings.

Identified opportunities and facilitated alternate care options based on member needs assessment.

Compiled, interpreted and presented clinical case data of all Medical Management reports.

Worked with staff to ensure compliance with all Federal, state and local regulations and regulatory mandates within established time frames.

Served as a clinical resource/educator for the Medical Management Department.

Manager Medical Management/Medicaid 5/2006-10/2008

Managed Medicaid team comprised of licensed RN’s and paraprofessional staff.

Provided ongoing clinical training.

Update policy and procedures and notifications of structural changes within the network.

Changed staff work assignments to achieve optimal outcomes.

Developed and analyzed reports necessary to monitor/track operational efficiency.

Conducted weekly clinical case conferences with staff.

Attended weekly meetings to discuss ongoing interdepartmental issues and staffing concerns.

Participated in a leadership role in medical management representing the Medicaid department externally to owner hospitals and ancillary providers.

Continuum Health’s MSO, New York, N.Y. 2001-4/2006

Assistant Director Clinical Services 5/2004-4/2006

Directed all Utilization Management, Case Management and Quality activities.

Assured functions performed by the RN and Intake Coordinator Staff were in compliance.

Collaborating with the Director, developed and implemented medical management policies and procedures to ensure efficient, high-quality, cost effective delivery of health care services.

Investigated all patient complaints, including readmission and incidents related to morbidity and mortality for Risk Management purposes as per HIP contract.

Assisted in developing UM/QA work plans in coordination with all related departments.

Developed strong communication links with network providers.

Developed and revised reports to assist in the assessment of the Intake Process as this related to utilization and quality management statistical activity.

Assist the Clinical Director and Medical Director in the annual review and updating of approved clinical standards, protocols and decision flow charts used in the authorization of services, and obtaining input from the Physician Oversight Committee.

Case Manager, Utilization Review, Appeals and Denials, 2001-5/2004

Quality/Risk Management

Identify members with one of the following diagnosis- asthma, diabetes, or CHF for disease management. Develop a treatment plan with the primary care physician and the member and evaluate, as needed, to determine the member’s progress and response to the treatment plan.

Conduct utilization review and medical case management for a high risk, high utilization population as it relates to pre-authorization and concurrent review for all lines of business.

Identify alternatives to acute level of care and promote earlier discharge through the use of case coordination technique and medical necessity criteria.

Review appeal requests following regulations, examining relevant data and summarize findings to forward to medical directors for final determination.

UnitedHealthcare, New York. N.Y. 1999-2001

Care Coordination Nurse Patient Advocate

Responsible for the clinical coordination of care and services for members who require acute care

by conducting telephonic reviews to evaluate medical information to authorize or deny plan benefit coverage of medical providers in accordance with established medical utilization criteria and policy and facilitate discharge planning and arrange for alternate services.

The Parkway Hospital, Forest Hills, N.Y. 1988-1998

Utilization Management/Quality Assurance Coordinator

Reviewed medical charts for the Medicare, Medicaid Systems and private Health Care.

Determined the appropriateness and quality of care of admissions and continued stays.

License and Certification:

Licensed Registered Professional Nurse in New York

Licensed Registered Professional Nurse in New Jersey

Certified Case Manager

Education:

1999

Hofstra University-Uniondale, N.Y.

Legal Nurse Consultant Program

Certificate in graduate level

1978

Adelphi University-Garden City, N.Y.

Bachelor of Science in Nursing

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