Case Manager Management
Resume:
Qualifications Summary
• Adept at leading all aspects of patient care, assessment, monitoring, and care plan development. Exceptional in providing patient support and reducing readmissions by effective management of homecare needs and follow-up calls.
• Demonstrated history of juggling multiple cases by delivering highest level of services. Committed to ensuring accuracy in patient documentation. Strong understanding of CMS Guidelines, policies, and procedures.
• Proven ability to build solid relationships with physicians, patients, care givers, and family members. As director, played a prominent role in forming strong teams and establishing an effective department from ground up. Career Experience
Brandon Regional Hospital Brandon FL 10/23/2023-6/3/2024 RN Case Manager/ UR Observation unit.
1. Conduct patient assessments develop discharge plan. 2. Assist with coordination of care and expediting services to decrease length of stay. 3. Utilization review for all observation patients to determine if they are in the appropriate level of care and review cases with attending physicians.
Banyan Medical Systems, Omaha Nebraska 07/19/2022-10/2023 Virtual RN Case Manager
Ini al assessments for high-risk pa ents. Determine discharge needs. Perform inpa ent u liza on review using interQual guidelines.
• Conduct virtual assessments develop discharge plan
• Conduct u liza on review for inpa ent cases and send reviews to insurers.
• Provide physicians with vital informa on in determining when a pa ent meets criteria for admission Aetna Health Plan, Bluebell, PA 01/2018 – 12/2020 Telephonic Case Manager
Performed telephonic evaluations for Aetna members. Built a plan of care as per members' medical and mental health requirements. Assessed care of care with primary care provider. Oversaw durable medical equipment, referrals, medical services, and mental health care in compliance with members' medical benefits.
• Effectively managed a 50-65-member caseload.
• Played a vital role in staff meetings, analyzed members' care plans to provide outcomes, and altered plan of care as needed.
Alta Vista Hospital, Las Vegas, NM 07/2016 - 07/2017 Director of Case Management
Directed case managers and collaborated with Regional Director of case management to track patients’ homecare needs. Established robust relationships with private practitioners and hospitalists. Prepared diagnostic assessments for high-risk patients and designed post-discharge questionnaires. Conducted in-service training for all the employees and directors on case management, workflow improvement, regulatory standards, length of stay initiatives, and best practices.
• Chaired the Utilization Management Committee.
Carol Sturniolo Piazza RN BSN CCM
Case Manager
************@***.*** • 516 - 287 - 2255
LinkedI n • Sun City Center, FL
Summary
Certified Case Management Professional with extensive leadership and management experience in the hospital and healthcare industry. Outstanding communication skills, poised to excel as case manager in hospital or health insurance organization. P a g e 2 3
• Pivotal role involved in TJC committee to generate recertification for Alta Vista and that successfully recertified in 2016. Saint Charles Hospital, Port Jefferson, NY 10/2015 – 04/2016 Interim Director of Care Management
Led 5 Nurse Care Managers, 8 Social Workers, 1 Appeals Nurse, and 1 Care Coordinator. Implemented the NYS Care Act policies and procedures. Trained staff on correct utilization of Care Act tool (developed in EPIC). Oversaw interdepartmental activities of bed flow, including daily bed board meetings
• Played a significant role in Joint Commission Prep team.
• Chaired the Care Coordination and Co-Chaired the Utilization Management Committee
• Transitioned Care Project by acting as a DISRIP Project Lead & hospital champion. Access Medicare, NYC, NY 04/2013 -10/2015
Director of Medical Management /Care Management
Supervised 5 Nurse Case Managers, 1 Health Advocate, 1 Care Representative, and 1 Authorization Specialist. Initiated Chronic Care Improvement Program, Quality Improvement Program, and Model of Care Program to meet the care management requirements. Provided operational guidance on CMS resources to address and deliver acute care services.
• Ensured patients received high-quality care by reviewing cases in collaboration with Chief Medical Officer.
• Effectively delivered information and advice to higher-level management related to medical management. Wyckoff Heights Medical Center, Brooklyn NY 11/2010- 1/2013 Director of Case Management/Utilization Management/Grievance & Appeals Lead and coordinated the team of 17 Nurse Case Managers and 4 Clerical Staff members on workflow activities such as Case Management, Utilization Management, and Grievance & Appeals. Introduced policies and procedures for Case and Utilization Management departments in adherence with Managed Care Organizations. Gathered and reported statistical data for Utilization Management and Length of Stay Committee. Performed regulatory requirements for Utilization Management, such as The Joint Commission, IPRO, CMS, DOH, and HMO’s. Developed and reported annual Performance Improvement Plan. Offered and implemented strategies for continuous improvement.
• Educated hospital and medical staff on denials and suitability of paperwork to support medical necessity.
• Delivered in-service training for CM/UM /G&A staff on utilization of resources, regulatory standards, workflow improvements, and LOS initiatives.
Additional Experience
Assistant Director of Quality, New York Eye & Ear Infirmary, NYC, NY Assistant Director of Case Management, Assistant Director of Case Management, HIP Health Plan of New York On-site Case Manager, Crawford and Company, Uniondale, NY Nurse Supervisor, Dr. Leddy and Valinotti, Brentwood/Bayshore, NY Director of Nursing for Day Treatment Program, Helen Keller Services for the Blind, Hempstead, NY Staff Nurse, Dr. Leddy and Valinotti, Brentwood, NY Geriatric/Urology/Med-surg Staff/Interim Charge Nurse, Maimonides Medical Center, Brooklyn, NY Oncology Staff/Interim Charge Nurse, Sloan Kettering Memorial Hospital, New York, NY Education
Bachelor of Science in Nursing
Hunter College Bellevue School of Nursing, NYC, NY Master of Science in Nursing Management and Leadership Walden University, in Progress
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Licenses & Certifications
Certification in Oncology, Adelphi University, 1984 Certified Case Manager Credential (CCM), Commission of Case Management, 1999 InterQual Certified, HIP Health Plan, 2001
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