Managed Care Case Manager
Resume:
PATRICIA C. HANNIFORD RN BSN, MSN
Royal Palm Beach
Florida 33411
Email - ************@*****.***
Nurse Executive with extensive experience in Managed Care specializing in Operations, Quality and Strategic plans. Goal oriented clinical leader adept at analyzing processes, creating, implementing and supporting new protocols, which will allow for continuous quality improvement. I am dedicated to driving organizational and cultural changes within the healthcare industry.
An experienced nurse with the adaptability and approach for transforming systems, products or services in Community health. A working knowledge of all lines of business – Medicare, Medicaid and commercial in Long Term Managed Care, Managed Service Organization and Certified Home Healthcare. I have a vast knowledge base on regulatory standards, quality, processes and clinical operations.
Wellington Regional Medical Center September, 2022- present
RN Case Manager, Discharge Planner & Utilization Review nurse.
Follow up on Length of stay, submit clinical for authorization
Review cases for discharges to post acute care
Transition care reviews and readmissions cases
New York City Health& Hospital – Contractual January 2021- August 2022
·Administer COVID 19 vaccine Pfizer and Moderna.
·Screen and evaluate patients post vaccination.
·Swab and complete COVID testing.
·Provide counseling and follow up clinical information to patients
·Assure compliance and eligibility for vaccine.
Jewish Board Family and Children Services
October 2018 – February 2022
Director of Medical Services
·Responsible for the Medical services for individuals with intellectual disabilities living in an Intermediate Care Facility.( 12 residences)
·Supervised the Medical team, which includes the nurses, physical therapy, speech therapy, Occupational therapy and Nutritionist.
·Reform the operation to integrate a computerized documentation platform for the clinicians.
·Act as a Liaison with outside Providers, Pharmacy and Physicians.
·Responsible for risk based oversight and quality reporting to the Justice Center of New York
·Oversight of the Education and training of the Direct Care Professional, who provides nursing care
·Consultant visit to the group homes within the system to conduct site audits of clinical records, meal observation, AMAP trainings and recertification.
·Provide coverage when needed for nursing triage calls from the group homes.
HealthCare Partners, IPA & Management Services Organization
Senior Director of Care Management September 2016-August 2018
Collaborate with the VP of Care Management to develop an Interdisciplinary team and a safety net of available resources to support complex and high-risk population.
•Developed a Transitional Care Program to manage members during inpatient and post discharge.
•Analyzed gap in patient care and work with the Primary Care Physicians to assure patients access to appropriate and adequate care.
•Proactive and predictive modeling of care within Case Management with a focus on the dual high-risk patients.
•Developed partnership with Providers to support community resources for high-risk patients.
•Demonstrated 8-10 percent reduction rate in readmission ( analysis of 2016-2017 admission rate data)
•Revised utilization management policies and procedures for Long Term Social Service to align with NCQA standards.
•Vice Chair, the NCQA Quality committee to assure Case Management policies and procedures met NCQA standards.
Center-Light Healthcare—Bronx, New York
Assistant Vice President of Clinical Operations/ Product Development 2013- April 2016
•Managed a team of 87 nurses, 10 Nurse Managers and 5 Clinical Directors.
•Developed training programs on requirements for Skilled and Non-Skilled Care in Community based services.
•Implemented criteria and guidelines for nurses to report clinical findings to the Care Manager.
•Create a team of Assessment nurses to do the Uniform Assessments required by the Health Plan for care planning and population health management.
•Act as the Clinical Lead during the Center for Medicare and Medicaid Services changes for Condition of Participation for Home care
•Designed a retrospective clinical review tool for the team to determine the members who required skilled care to transition to a Certified Home Health Agency.
•Retained an additional 350 members from transitioning to the CHHA by developing Blister Packaging Program – this decreased the number of nursing visits needed per member from 12 visits to 6 visits every 6 months.
•Managed the operations of the Uniform Assessment System by developing policies and procedures, guidelines and role assignment for Center -Light Uniform Assessment case-list.
•Developed Risk Stratification criteria and training program to the Care Managers to safely transitioned members from MLTC – PACE program- This increased development and growth of the PACE program a total of 450 members requested to transitioned.
•Participated with the Leading Age of New York on the Clinical Advisory Group on the introduction of MLTC Value -Based payment initiative.
Center-Light Healthcare - MLTCP
Regional Clinical Director 2011- 2/2013
•Created tools for retrospective and concurrent reviews to determine medical necessity for services.
•Document and approve services based on clinical review conducted by the Nurse Care Managers.
•Generate Notice of Action letters, Grievance and Appeals notices to the members.
•Developed policies and procedures to meet the contractual agreement between the New York State Health Insurance and the Managed Care Organization (MCO).
•Managed the Intensive Care Management program to assure that the high-risk member’s clinical issues were addressed.
•Lead the quality measures initiative for MLTC and participate as a member on the Quality Improvement Committee.
•Developed strategic initiatives to decrease dis enrollment by creating a committee to review and discuss the reason for dissatisfaction and dis enrollment from the program.
•Collect and trend data to develop training program to increase member’s satisfaction.
•Managed the enrollment of the member to the program by the creation of tracking tools to assure appropriate start of care.
Nurse Care Manager 2008- 11/2011
•Supervised the Community Health Nurses (6) and managed a census of 225 members.
•Coordinate the covered and non-covered services in the MLTCP.
•Review and track clinical assessments to assure timely and accurate completion.
•Facilitate care planning, authorization of services and review of members Skilled Nursing Home stay.
•Conduct field visits to assure that the Community Health Nurses maintained good quality and standards of care.
Jewish Home Life Care Services – New York, NY
Performance Improvement & Quality Manager (OASIS Certified) - Community Service Division 2006- 4/2008
•Formulated policies and procedures to insure compliance with JCAHO regulatory standards.
•Review OASIS assessment to increase submission rate of the RAP for each episodic care.
•Conducts Medicare PPS billing meetings with Clinical and Financial department.
•Train new staff on documentation on the Electronic Medical Record.
•Created teams report to demonstrate productivity and quality of care by the staff.
•Collect and trend data for quality improvement measures.
•Team Facilitator to monitor the telemedicine program by triaging the triggers generated by the patient’s responses.
Nursing Supervisor- Community Service Division 2002- 1/2006
•Facilitated cost-effective utilization of resources via review of services and 120-day HRA budget assessments.
•Supervised a district with over Medicare/Medicaid patients; oriented all newly hired RN staff.
•Case reviews to assure adequate and appropriate services to the patients.
•Conducted regular meetings to facilitate staff involvement in generating problem solving strategies.
Unit RN Charge Nurse - Skilled Nursing Facility 2000- 2/2002
•Completes MDS assessments for assigned patients on the unit.
•Managed a team of 5 Certified Nurse Assistants by developing their assignments for patient care.
•Perform medication administration, wound care and tube feedings.
•Completes 24 hours’ documentation and care planning.
Other Positions Included:
Clinical Nurse – Gerontology, Vascular/ Telemetry Unit (Night shift) 2004- 2012
EDUCATION
Aspen University – DNP program Anticipated – January 2023
Hunter College, New York, NY Degree: January 2012
Master of Science in Community Health.
SUNY Downstate Medical Center, Brooklyn, NY Degree: May 2008
Bachelor of Science - Nursing
Medgar Evers College, Brooklyn, NY Degree: June 2000
Associate in Applied Science - Nursing
Conferred: Summa cum Laude
Contact this candidate