Case Management Manager

Location:

Springfield, MO

Posted:

November 17, 2023

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Resume:

Professional Profile

Aspiring to obtain a challenge position utilizing my years of success in leadership and case management.

Goal oriented individual with strong leadership capabilities

Ability to direct complex projects from concept to fully operational status

Ability to work in unison with staff and administration to achieve results

Organized, initiative-taking, detail-directed, analytical

Professional Experience

TRISTAR Managed Care October 2017 – Current

Utilization Review Supervisor - current

Responsible for the supervision of Utilization Review for Workers Compensation for multiple states. Adhere & maintain URAC

accreditation. Attends Quality Management Committee to inform the committee of new utilization regulations. Develops &

implements internal procedures & workflows adhering to URAC standards. Coordinate UR with peer physician vendors.

Confers with Medical Director. Conducts reviews of quality performance indicators.

Case Management Group Health & Wellness Supervisor - current

Responsible for the supervision of Group Health & Wellness Program and Pharmacy Weaning staff. Streamlined internal processes and created workflow for every position. Designated the expert for the Group Health / Wellness operating system including development of letters, workflow, and configuration. Established client reports regarding return on investment for Wellness. Developed new Condition Management Program for Diabetes including P&P, workflow, client reporting and letters.

Health Systems Inc. September 2016 – July 2017

Managed Care Corporate Case Manager

Responsible for Utilization Management with all managed health plans and commercial insurance payers for forty-two (42) skilled nursing facilities. Identify trends with readmission rates and over utilization. Provided education to all facilities and administration regarding over utilization and compliance.

Select Specialty Hospital October 2008 – August 2016

Director of Case Management Springfield / Senior Case Manager Corporate

Responsible for relationships with referral sources. Supervises Case Managers and assists with conduction of patient treatment plans. Participate in Quality Assurance Improvement Programs. Working knowledge of Outlier Management to ensure fiscal management. Perform weekly audits to ensure compliance with Medicare Condition of Participation. Oversee interdisciplinary projects discharge planning activities. Coordinates with Central Billing Office regarding Medicaid Spend Down and Medicaid pending patients. Perform and oversee Utilization Management to include Milliman & InterQual guidelines.

Senior Case Manager

Oversee ten (10) Select Hospital Case Management departments. Responsible for on-boarding/training new Case Managers. Establish relationships and communication with new Case Managers to assist them with complex cases and fiscal management.

Cox HealthPlans August 1998 - October 2008

Director of Utilization Review/Case Management, from January 2007 to October 2008

Responsible for effective and efficient functioning of the Medical Department including the organization, management and development of utilization management, case management, and disease management. Ensure compliance with nationally recognized accreditation and governmental standards, as well as compliance with UR/CM standards. Oversee committees and procedures for UR/CM. Oversee staff to ensure that staff practices case management within the scope of their licensure. Monitor and evaluate the effectiveness of programs and procedures and implement changes as indicated. Monitor UR/CM committee structure activity including policy and procedure, quality assurance, program content and resource education committees to ensure departmental consistency.

Medical Department Manager, from January 2006 to December 2006

Medical Department Supervisor, from February 2005 to December 2005

Case Manager, from August 1998 to January 2005 - Oncology

Columbia Home Health January 1995 - August 1998

Team Leader, from May 1996 to August 1998

Home Health Nurse, from January 1995 to May 1996

Republic Park Care Center December 1993 - November 1994

Assistant Director of Nursing

Education

St. John’s School of Nursing, Springfield, MO - Attained RN Diploma Degree, Nursing, December 1993

Southwest Baptist University, Springfield, MO -RN Prerequisites for St. John’s School of Nursing, May 1992

Graff Vo-Tech, Springfield, MO - Received license as LPN, August 1989