Donna Calderon

Punta Gorda, FL *****

ad5ak0@r.postjobfree.com

+1-305-***-****

Positions held: Director CRI Denials Prevention & Management, National Director of Operations, Director of Business Development, Executive Operations Officer and Executive Director, Sr. Healthcare Auditor, Director Utilization Review, Care Management, Clinical Documentation, Revenue Integrity, Grievance & Appeals

Revenue Cycle, Denials, Grievance, RAC, Strategic planning, Six Sigma, implementations, administering long and short-term goal to successful conclusion.

Quality Improvement based reimbursement initiatives Restructuring, Policies and

Procedures. Management of CQI initiatives, Project Management, Organizational design/redesign, development, performance Indicators, analysis and synthesize data for presentation of useable information. Developed and presented findings and recommendations to leadership. Recovered in excess of 17 million yearly.

Operations oversight of Risk Management, Hospitalist Program, Quality Improvement,

Credentialing and Delegation Oversight, Hiring Training and Development of personnel, all levels’, ICD 10 Implementation

Operations Management of Call Center, Referrals, Pre certifications, Discharge Planning Utilization Review, Case Management, Disease Management, Clinical Documentation Improvement

People oriented problem-solving skills, excellent negotiating & communication skills. Dedicated organized professional.. Ability to work effectively with ambiguity.

Thorough understanding of current regulations for services, AHCA, NCQA, HCFA, CMS, HIPPA, JACHO, Medicare,Medicaid,ManagedCare

Work Experience

Independent Healthcare Consultant

Punta Gorda Isles, FL May 2020 to Present

Transition and Integrations, Education on Current Trends, Client Facing, Remote Utilization Review, Case Management,

Revenue Integrity, Appeals & Denials Interim Leadership

Director CRI Denial Prevention and Management

Ciox Healthcare - Alpharetta, GA December 2017 to April 2020

Director CRC CHI Transition and Integration

Conifer Health Solutions - Frisco, TX January 2012 to November 2017

Independent Healthcare Consultant

Punta Gorda Isles, FL

March 2011 to January 2012

Director Case Management UR and CDI Fawcett Memorial Hospital - Port Charlotte, FL February 2009 to March 2011

Senior Healthcare Auditor Manager UR and Case Management

Miami, FL

September 1999 to February 2008

Utilization & Care Management Jackson Memorial Hospital South - South October 1999 to May 2004

Weekend Hospital Case Manager/UR

Admissions Nurse, Community Service Director

Vitas Hospice Care

August 1990 to September 1999

Education

Masters in Healthcare Administration

Mercy Hospital School of Nursing

Skills

•Utilization Review

•NCQA Standards

•ICD-10

•Six Sigma

•Operations Management

•Documentation Review

•Program Management

•Strategic Planning

•Case Management

•Utilization Management

•Business Development

•Organization Design

•HEDIS

•Quality Management

•ICD-9

•Process Improvement

•Medical Terminology

•Nursing

•CPT Coding

•Managed Care

•Management

•Medical Records

•Medical Billing

•Change Management

•Negotiation

•Employee Orientation

•Recruiting

•Project Management

•Workers' Compensation

•Medical Coding

•EMR Systems

•Insurance Verification

•Quality Assurance

•Human resources

•SharePoint

•Regulatory reporting

•Content management systems

•Data analytics

•Customer service

•Telecommunication

•Windows

•Presentation skills

•Revenue cycle management

•Financial analysis

•Succession planning

•Financial planning

•Continuous improvement

•Business analysis

•Agile

•Financial acumen

•Microsoft Excel

•Microsoft Powerpoint

•Microsoft Access

•SAS

•SQL

•Teaching

•Customer support

•Profit & loss

•Epic

•Bilingual

•Healthcare management

•Live chat

•Motivational interviewing

•Data management

•Pivot tables

•Employee relations

•Conflict management

•Kronos

•Operating systems

•Project leadership

•Forecasting

•Sales

•HCPCS

•Product management

•P&L Management

•ICU experience

•Communication skills

•Root cause analysis

•Contracts

•Events management

•Database administration

•Mac OS

•Google Suite

•Payroll

•Network management

•Patient monitoring

•Talent acquisition

•Performance Management

•Budgeting

•Data Warehouse

•Oracle

•Jira

Languages

•English and Spanish - Fluent

Certifications and Licenses

Certified Case Manager Accredited Case Manager AHIMA

LPN

Six Sigma Yellow Belt Six Sigma Certification Certified Notary Public

Medical Billing Certification

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