Management Medical
Resume:
KATHERINE M. NEWCOMER
*********@*****.***
PROFESSIONAL SUMMARY
** ***** ********** ** *** - both inpatient and outpatient
** ***** ********** ** ****** plan setting in:
oUtilization Management
oQuality Management
oGrievance and Appeals
Management, Implementation, and Training of new Medicare Utilization Management team
oManagement of up to 30 nursing staff
Key role in design and implementation of new medical management system
Key role in design and implementation of new claims, member, and provider information core system
Key role in implementation and sustainment of ongoing process improvement projects
5+ years experience with Medicare and Medicaid criteria and guidelines
HEDIS data collection review, abstraction and submission
SKILLS and AREAS OF EXPERIENCE
Patient care in inpatient and outpatient settings
Medicare, Medicaid, Interqual, Milliman, and Apollo guidelines and criteria
Creation and implementation of training plans
Management and Supervisory in multiple settings
Electronic Medical Record documentation
Microsoft Office Suite
Medical Management Systems software design and implementation
Core system for claims, member and provider information software design and implementation
EDUCATION
Riverside Community College
Riverside, CA
Community College of the Air Force/ Sheppard AFB Hospital
Wichita Falls, TX
LICENSURE/CERTIFICATIONS
California LVN licensure since 1988
IV Certification
BCLS Certification
Federal Urine Drug Screen Collection, Breath Alcohol Testing
WORK HISTORY
08/2010 – Present
Inland Empire Health Plan (IEHP)
Rancho Cucamonga, CA
Outpatient Utilization Review – Medicare/Dual Choice Manager
oManagement of 30 review nurses
oEnsure compliance with Medicare and Medicaid guidelines and deadlines
oAssist with preparation for audit by multiple oversight organizations
oParticipate in training of delegated IPAs
oDevelopment and implementation of training for new staff, and ongoing focused training
oLeadership and supervision of day to day medical management functions to ensure high quality, cost effective services to health plan members
oInterface with key department managers to resolve issues and establish or refine policies and protocol
oAssist in the development and annual review of internal and external Policy and Procedure Manuals
4/2010 – 7/2010
Family Practice Medical Group of San Bernardino, Inc.
San Bernardino, CA
Utilization Management Department Manager
oManagement of 3 department staff
oEnsure compliance with Medicare, Medicaid, and commercial plan guidelines and deadlines
oAssist with preparation for audit by multiple oversight organizations
oEnsure timely submission of reports to multiple oversight organizations
oAssist with coordination of discharge plans for members
oLeadership and supervision of day to day medical management functions
oAssist with Health Risk Assessment calls to plan Medicare members
9/2008 – 2/2010
Vantage PPMC, Inc.
Riverside, CA
Utilization Management LVN Lead
oReview and adjudication of prior-authorization requests for medical necessity and appropriateness of service and care utilizing industry standard review guidelines
oIdentification of prior authorization requests requiring Medical Director review
oCrafting of denial letter as appropriate
oTraining and semi-supervision of UM nursing staff
oTimely and appropriate documentation in the medical management system
oIdentification of potential cases for Case Management, Disease Management, Health Management, Health Education and/or quality of care issues and making appropriate referrals to Care Management team when needed
oResponsible for identifying alternate payer sources such as CCS and IRC
3/2003 – 3/2009
USAF Reserves, 452 AES
March ARB, CA
Aero-Medical Evacuation Technician
oCare for, observe, and report on postoperative patients and seriously or critically ill and injured patients during medical evacuation flight
oProvide primary emergency medical response to in-flight emergencies and potential mass casualty scenarios from on- and off-base incidents
oOperate emergency medical and other vehicles, load and unload litter patients
oIdentify patient problems and assist in developing and evaluating patient care plan, prepare and administer medications under nurse or physician supervision
oManage supplies and equipment, submit and execute budgets, schedule personnel for duty, Supervise personnel and conduct training
oAdditional duties of Designated Squadron Anti-Terrorism officer, Safety officer, and Operational Risk Management officer.
oResponsibilities for additional duties include ensuring routine safety inspection of squadron work spaces, performing and maintaining a record of initial and annual safety and operational risk management training, reviewing work spaces and performance of duties for potential risks, development of plans for risk mitigation, conduct periodic training, fire drills, and evacuation procedures, conduct periodic and annual anti-terrorism briefings
6/2006 – 9/2008
St Jude Heritage Healthcare
Fullerton, CA
Quality Management LVN
oInvestigate and recommend course of action for all member grievances and appeals, gathering of additional documentation, maintain record in plan data base, track and trend occurrences and recommend corrective action plans
oPerform annual Quality Improvement projects as determined by department director
oResponsible for reviewing and abstracting medical records for the annual HEDIS project with documentation of related items into project data base, review and integrate medical information from electronic and paper medical records in compliance with project timeline, travel to provider offices for additional record review and copying for project
oPeriodic and annual visits to provider offices to perform inspection of site and random sampling of medical records to ensure compliance with plan standards for credentialing and re-credentialing
10/2005 – 6/2006
Molina Healthcare, Inc.
Long Beach, CA
Prior Authorization Review LVN
oReview and adjudication of prior-authorization requests medical necessity and appropriateness of service and care based on industry standard guidelines
oIdentification of prior authorization requests requiring Medical Director review
oCrafting of denial letter as appropriate
oTimely and appropriate documentation in the medical management system
oIdentification of potential cases for Case Management, Disease Management, Health Management, Health Education and/or quality of care issues and making appropriate referrals to Care Management team when needed
oResponsible for identifying alternate payer sources such as CCS, or other carve-out benefit
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