Manager of Case Management- Social Worket
Resume:
PROFESSIONAL SUMMARY
* ***** ** **** ********** leadership experience. Background includes Acute, LTAC and Surgical Hospital Setting, in addition to insurance case management. Driven and compassionate healthcare professional with 20 years of discharge planning in various fields. SKILL HIGHLIGHTS
ICU, Medical-Surgical
Transplant
Oncology
Psychiatry
Rehabilitation
Skilled Nursing
Home Health
Hospice
PROFESSIONAL EXPERIENCE
Houston, TX
Foundation Surgical Hospital/ Jul 2016 to Jan 2017 Responsible for communicating with physicians, executive team and other departments process issues limiting clinical achievement and financial performance goals relate to care coordination and utilization management.
Overseeing utilization management process for 69 bed facility, compliance with state and federal guidelines.
Participate in gathering and maintaining PI and Quality Data reporting purposes such as length of stay, avoidable, denial and appeals.
Development and continually updating all processes policies/procedures within the department.
Lead Case Manager
Houston, TX
Cornerstone Hospital Houston Medical Center/ Oct 2012 to Jul 2016 Routinely review outside procedures and making recommendation for stream-lining or improvement to minimize facility cost.
Establish daily clinical documentation review process for DRG coding changes and avoidable days.
Created dashboard metrics targeting corporate goals of Census, Case Mix Index and Length of Stay for fiscal compliance.
Communicated routinely expected business challenges, ethics,state and federal regulatory compliance requirements to all department heads. Director of Case Management
Houston, TX
St. Antony's Hospital/ Oct 2011 to Oct 2012
Implemented the installation of InterQual criteria for training physician/nursing to improve work methods and procedures towards achieving revenue objectives for 39 bed facility.
Establish periodic concurrent and retrospective review of denials and submit appeals for reimbursement.
Collaborate with Utilization Review Committee in evaluating patterns and improving clinical documentation challenges.
Senior Case Manager
Houston, TX
Kindred Hospital/ Aug 2009 to Mar 2012
Responsible for completing medical necessity for 20 plus caseload. Communicate with external case managers for continued stay, based on patient acuity level using InterQual criteria.
M .
Linda G.
Mayshack
*********@*******.**
m
2250. Gessner #311
Houston, Texas, 77063
Identify and document variances related to length of stay, quality and risk issues . Collaborate with the interdisciplinary team on discharge planning needs. Case Manager/Medical Social Worker (Staffing Agency) Houston, TX
Social Work P.R.N/ Jul 1995 to Nov 2009
Case Manager for St.Lukes Episcopal Hospital Transplant unit, utilizing Interqual criteria for inpatient stay.
Act as Social Work Counselor for Thoracic & Head/Neck, Urology, Leukemia & Myeloma at MD Anderson Cancer Center.
Assessment of patients for social/economic resource options in addition to counseling for long range planning and decision making prior to discharge at Kingwood Medical Center.
Clinical Care Manager
Houston, TX
Evercare Texas/ Oct 2005 to Jan 2009
Conduct face to face and telephonic assessments to create plan of care for clients requiring in home services such as PAS.
Assess and refer patients for management of disease process. Utilize InterQual and Milliman criteria as pre-certification for SNF's, PT and OT needs. Educate members on Medicare and Medicaid guidelines for Traditional and HMO benefits.
Act in the capacity of Resolutions Coordinator for Health and Human Services Commission complaints sent to Evercare related to member and vendor issues. Utilization Review Case Manager/Medical Social Worker Houston, TX
Twelve Oaks Medical Center/ Jul 1999 to Aug 2004
Provide utilization review case manager for Rehabilitation, Skilled Nursing, Spine, Telemetry, Med-Surg, ICU, ER, Psychiatry, Admissions, Outpatient and Maternal Child units.
Conduct retrospective audit of payer denials to assist with payment reimbursement for patient stay, including Prospective Payment.
System (PPS) for rehabilitation and skilled nursing units Initiate psycho-social assessment and discharge planning for assigned case load daily. Communicate with physicians, staff, patients and family the plan of care for movement throughout the continuum of care.
EDUCATION AND TRAINING
Masters of Social Work
University of Houston 05/97
Houston, TX
Bachelor of Arts
Texas Southern University 05/93
Houston, TX
SKILLS
Case Management, Counseling, PI & Quality data collection and process improvement,,Discharge planning, Clinical documentation improvement, Coding, psycho- therapy, Marketing, Treatment care plans.
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