Management Medical
Resume:
Yvonne Fernandes, BSN, RN, CCM, CMCN
Saint Albans, NY 11412
********@***.***
Experience:
SUNY Downstate Medical Center
Director of Care Management
Oversaw Care Management which consisted of Case Managers, Social Workers/Discharge Planners and Clinical Documentation Specialists.
Planned, developed, organized, implemented, evaluated and administered Care Management programs and initiatives in accordance with objectives of hospital administration and medical staff.
Participated in the development of effective hospital-wide Care Management strategies, ensuring compliance with external accrediting agencies and patient care review requirements including but not limited to JC and IPRO.
Ensured compliance regarding resource allocation, discharge planning and social work intervention processes in accordance with regulatory agencies including but not limited to DOH, TJC, CMS, IPRO, OMH and other local bodies of authority, and acts as a liaison for the same.
Supervised the integration of the activities of the departments assigned so the objectives of the Care Management programs were accomplished.
Provided mechanism for discharge planning via hospital-wide implementation of Care Management plan and updated high risk screening criteria on an ongoing basis in order to capture the needs of the community.
Tracked and analyzed data generated through internal and external sources such as patient care evaluation studies, length of stay, variance analysis, financial reports, departmental reviews and other operational reports for the purpose of clearly identifying issues.
Coordinated and participated in special multi-disciplinary projects with appropriate hospital staff.
Collaborated with and provided technical and consultative support to Chiefs of Service, Chief Medical Officer and other administrative positions.
Collaborated with hospital administration in identifying areas of concern and improvement based on case mix, length of stay and other variance analyses.
Presented as the resource person for all hospital employees and medical staff regarding Care Management.
Maintained up-to-date departmental operations policies and procedures.
Demonstrated leadership skills for all personnel within departments including assessing potential problems or risks and addressing them.
Supported and provided clear direction and priorities for staff within department to ensure high departmental productivity and functionality.
Served, in conjunction with the physician champion, as a resource for difficult Care Management cases to departmental staff.
Represented Care Management and participated in appropriate hospital meetings including but not limited to Provision of Care, Revenue Cycle, Utilization review and Patient Throughput Committees.
Managed fiscal and human resources in an efficient manner in accordance with the departmental budget.
9/2012-10/2014
North Shore LIJ Medical Center
Assistant Director of Case Management
Oversaw the daily functions of Case Management Services inclusive of concurrent review, discharge planning, and denial and appeals
Assisted with systems, processes, and outcomes of clinical care teams and programs designed to address clinical, psychosocial, and financial needs of patients and families
Participated in training, supervision and evaluation of team members
Participated in goal setting, program planning, workflow process monitoring, regulatory compliance, staff productivity, and assessment of good customer service, quality of work, outcome evaluation, and continuous quality improvement
Represented the organization to internal and external customers including patients and families, physicians and ancillary medical personnel, service leadership, administration, other sister hospitals, health plans and other third-party payers
Along with senior administrative director, collaborated with hospital directors and establish goals and objectives for the department
Developed strategies and programs to achieve goals
Developed and implemented policies and procedures supporting quality patient driven care through efficient and effective case management
Guided, mentored, motivated and engaged the staff in assessing, planning, implementing programs and evaluating patient care according to patient satisfaction and positive outcomes
Screened and investigated case management incidents and patient complaints and determined follow up and initiated corrective action
Assessed staff’s ability to manage and analyze patients total care needs across the continuum and developed short and long term goals
Collaborated with Patient Accounts/Finance, HIM, CDI leadership to maximize reimbursement
Oversees denial and appeals process inclusive of RAC, MAC and IPRO
Interviewed, hired, developed, managed and evaluated direct reports as well as interacted and collaborated with the interdisciplinary team
Promoted and encouraged staff development and education
Established standards for performance and ensured timely completion of performance appraisals
Audited staff work and ensured criteria and guidelines were followed that supported evidence base practice
10/10-9/2012
Amerigroup Community Care
Director HCMS-UM
Oversaw the daily functions of Health Care Management Services inclusive of pre-certification, concurrent review, discharge planning, and denial and appeals
Oversaw review of concurrent, and retrospective review cases in conjunction with reviewing high-dollar cost outlier claims
Participated in and managed healthcare management utilization, cost, and quality objectives in accordance with departmental and company goals
Supervised managers, senior care specialists and all other direct reports within HCMS UM
Collaborated with peers to initiate innovative care pilots to improve overall HCMS program
Oversaw the development of policies, procedures and guidelines and ensured information was disseminated to leadership and staff
Supported and participated in quality initiatives and activities including clinical indicators reporting
Identified complex and long length of stay cases and matched to APR DRG payment methodology
Ensured NOMNC were sent in timely manner to agencies and members
Performed and oversaw auditing of the clinical and non-clinical staff
Key participant in reviewing NCQA readiness for look back period
Key participant in streamlining policies, procedures, workflows during HealthPlus acquisition
07/09-9/2010
Lutheran Medical Center
Assistant Director of Appeals
Oversee the denial and appeals process within the Case Management Department
Reviews denial and responds to third party by conducting written standard appeals and expedited appeals when warranted
Assures appeals and responses meet contractual and regulatory obligations
Tracks and trends denial utilizing database
Interprets data and identifies area for process improvement
Educates case managers and consults with physicians regarding denials and criteria
Liaisons with Third Party Payers and QIOs to streamline denial and appeals resolution
Interface with Maximus, CMS and DOI regarding pursuing of External Appeals
Oversees production and distribution of internal reports as requested
Research denial and appeal issues in conjunction with communicating with Patient Accounts, and other departments regarding denials and appeals resolution
11/08-7/09
Tact Medical Staffing:
Assistant Director of Hospital Appeals, at Queens Hospital Center (Temp position)
Assisted in the development of departmental policies, goals, performance improvement projects, presentation and training sessions
Discussed denials with case managers and played an active role in minimizing days denied by assisting with procurement of documentation needed to reverse denial
Liaison with third party agents to ensure timely compliance with review requirements and also provided retrospective clinical reviews when needed
Monitored the timeliness of the certification activities and the submission of the clinical information and assisted with concurrent reviews
Participated in departmental staff orientation and training and developed training materials and provided in-service for staff and physicians based on identified needs
Maintained current knowledge of federal, state and JCAHO guidelines and applied them to activities of the department
Oversaw all third party denial and appeal activities including the external second level appeals
Tracked, monitored, and oversaw the concurrent denials issued by all third party payers including IPRO & RAC and initiated intervention to minimize the days denied
Coordinated responses to third party payers for cases requiring physician’s input and reviewed responses from physicians for appropriateness and adequacy
Communicated with managed care companies to obtain processes in order to streamline workflow and problem solve issues as they arose
Maintained master computerized and manual database of all audit information from initial requests through conclusive determinations
Prepared and submitted weekly, monthly and quarterly trending report by service regarding the number of denials, determinations and DRG analysis
Prepared and submitted quarterly Board reports for all third party denial activities
Coordinated all functions of the UM Committee including the minutes and reports
12/31/07-5/08
Americare CSS Homecare
Director of HMO
Provided clinical and general support to clinical and clerical staff in the delivery of client care
Evaluated the performance of assigned staff in meeting productivity and quality standards
Supervised adherence to established time frame in receiving and completing 485's
Participated in quality assurance activities including formal and informal audits
Contacted the managed care organizations to discuss case concerns, issues, guidelines and timeframes
Ensured that authorizations obtained were data entered in timely manner to help streamline the billing process for patients being seeing in the Adult Homes
Investigated and researched billing/claim payment issues with the managed care companies and the billing department
Verified third party coverage and eligibility via the applicable program such as EMEDNY
Reviewed the denials that were received from HMO's and the appeal information that was submitted to the managed care organizations for reconsideration
7/00 -1/08
HIP of Greater New York
Director of Continuing Care, 6/03-1/08
Performed oversight and management of Assistant Director, Care Managers and clerical union staff
Managed all activities in Home Care, DME services and End-of-Life Program process, including staffing requirements in order to ensure prompt and accurate handling of requests
Oversaw the review of home infusions and enteral cases to ensure medical necessity was being met and that care could be safely provided in the home
Assisted with the preparation and maintenance of approved departmental budget
Developed and maintained policies and procedures within Home Care/DME and End-of-Life subunits to meet State, NCQA, URAC, DOH, DOI, and HIP guidelines
Consistently promoted departmental goals and implementation of activities to meet or exceed strategic plans
Analyzed departmental utilization reports and reported all required data
Maintained effective liaison and working relationships interdepartmentally and with providers, members and regulatory agencies to assure appropriate and timely delivery of service
Assistant Director Pre-Authorization, 7/00 - 6/03
Managed and delegated assignments to a staff of twenty-five nurses
Planned and managed all activities relating to the pre-certification of scheduled surgical procedures and home care processes
Ensured efficient and effective daily operations of the department
Directed orientation of new staff and monitored performance of clinical staff to ensure departmental and organizational goals were met
Performed probationary and annual reviews of staff
4/99 - 6/00
CBB Medical Services
UM/QM Coordinator
Performed concurrent utilization review of all admissions
Conducted daily telephone rounds with physicians and HMO case management
Evaluated appropriateness of acute care service, discharge planning and case management needs
Calculated length of stay for each admission using DRG guidelines and reviewing cases with physicians
Conducted retrospective review of medical records for non authorized services, admissions appropriateness and medical necessity of length of stay
Conducted and documented quality monitor checks for inpatient and outpatient services
Participated in Quality Management committee meetings
Education/Certifications/Memberships:
University of Phoenix Online, BSN
Borough of Manhattan Community College, AAS
PRI Assessor #64236
Certified Case Manager
Certified Managed Care Nurse
Member of Sigma Theta Tau; Member of CMSA
Member of American Association of Managed Care Nurses
Skills/Knowledge:
MS Word, Outlook, Excel, Canopy, Misys, 3M, Navigant CDI Monitor, Altuista, HealthBridge,
Medicare, Medicaid, Aetna, Apollo, Milliman & InterQual Criteria
Contact this candidate