Case Management Utilization
Resume:
DECORAH D. PIERCE, MBA, BSN-RN, CCM, LSSGB
Healthcare Management Executive Expert in Utilization & Case Management Strategic Leader in Clinical Operations
*************@*****.***
Pearland, Texas 77584
Executive Summary
Results-driven healthcare management executive with deep expertise in Care and Utilization Management, recognized for leading high-performing teams and optimizing clinical operations across both hospital and managed care settings. A strategic leader with a proven track record in operational excellence, regulatory compliance, process improvement, and consistently driving significant cost savings and quality enhancements. Known for blending assertive leadership with compassionate care, I am dedicated to advancing patient outcomes while ensuring financial sustainability.
Work Experience
Apex Health Solutions for Memorial Hermann Health Plan- Director, Health Services
Houston, TX 01/2021 - Current
Strategized and restructured utilization management BRD’s, SOP’s, and workflow leading to a 20% reduction in medical loss ratio.
Led HealthEdge/Guiding Care UM system implementation resulting in enhanced operational efficiency by 25%.
Developed and led implementation of strategic clinical operational plans for utilization management teams, improving key indicators (TAT, ADK, BDK, ALOS, etc) through efficient workflows and establishment of best practices
Tele-Med Surg RN (Contract)
RN Network: Houston Methodist & Memorial Hermann
Houston, TX 3/2020-1/2021
•Provide primary care to critically ill patients in medical surgical and tele units.
•Coordinate and direct supportive staff to ensure patient’s needs are met and hospital policy is followed.
Kindred Hospital - Director of Case Management
Chicago, IL 03/2016 – 07/2019; Houston, TX 07/2019- 03/2020
•Served as Director of Case Management overseeing both a Long-Term Acute Care (LTAC) unit and an Acute Psychiatric unit, ensuring seamless coordination of care, optimizing patient outcomes, and managing complex cases across these distinct healthcare environments
•Drove significant financial performance by leading highly effective teams, streamlining discharge processes to meet length of stay benchmarks, and achieving 95% insurance approval for hospital stays
•Relocated to Houston Heights hospital in 2020. Hospital closure in 2020.
Family Health Network, MCO - NCQA UM Accreditation Manager
Chicago, IL 01/2015 - 01/2016
•Exceptional cross-functional collaborator to the goal of Health Plan NCQA accreditation
•Designed and implemented SOP’s and a training program compliant with NCQA and CMS regulations.
Unite Here Health, TPA - Regional Nurse Case Manager
Chicago, IL 01/2014 – 09/2015
Directed daily operations of utilization review and case management teams.
Employed assertive and self-motivated strategies to improve process efficiencies and reduce out of plan utilization
North American Medical Management - UM and Care Coordination Manager
Hillside, IL 01/2013 - 01/2014
Ov Results-driven healthcare management executive with deep expertise in Care and Utilization Management, recognized for leading high-performing teams and optimizing clinical operations across both hospital and managed care settings. A strategic leader with a proven track record in operational excellence, regulatory compliance, and process improvement, consistently driving significant cost savings and quality enhancements. Known for blending assertive leadership with compassionate care, I am dedicated to advancing patient outcomes while ensuring financial sustainability.ersight of UM and care coordination functions for contracted Health Plan clients.
Project lead for care management system implementations
AIM Specialty Health/WellPoint Inc - Clinical Operations Manager, Quality Auditor
Deerfield, IL 01/2007 - 01/2013
●Orchestrated the development of training programs, workflows, and quality auditing tools for clinical operations.
Other Relevant Experience
ICU, Tele, Med-Surg RN (Contractor), Acumen Medical Staffing / Chicago, IL 2006-2020
Nurse Clinician I, Advocate Health / Oaklawn, IL 2005-2006
LPN/RN/Night Supervisor, HCR Manor Care / Oaklawn, IL 2002-2005
Skills
●Strategic Planning & Process Improvement
●Utilization Management & Review Benchmarking
●InterQual/Milliman/Hayes Technology
●Case Management & Discharge Planning
●Performance Improvement & Quality Management
●Interdisciplinary Collaboration & Community Resources
●Assertive Leadership & Supervisory Experience
●Compassionate Care & Service Excellence
●Effective Written & Oral Communication
Education
●MBA: Health Care, University of Phoenix, 2012
●BSN, University of Phoenix, 2008
●AAS: Nursing, Richard J. Daley College, 2005
●Certificate Program: Nursing, Chicago Public Schools, LPN Program, 2002
Certifications
●Certified Case Manager (CCM) 2020
●Lean Six Sigma Green Belt-2019
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