Case Management Manager

Loree J. Fink, RN, MSN, CCM

CONTACT INFORMATION

Address (H): 108 Blue Canyon Way, Folsom, CA 95630

Phone: 661-***-****(C)

Email: *********@***.***

PROFESSIONAL PREPARATION

Academic Preparation:

Institution

Degree

Major

2011

Walden University, Minneapolis, MN

MSN

Nursing

2000

California State University, Northridge (CSUN)

Northridge, CA

BSN

Nursing

1992

Los Angeles Pierce College

Woodland Hills, CA

ADN

Nursing

Professional Licensure & Certifications:

Licenses:

Registered Nurse, CA license # RN482559, through 07/26

National certifications:

Certified Case Manager (CCM) # 00131505 through 11/29

WORK EXPERIENCE:

Centene Corporation, Manager of Care Management,10/2017 to 12/1/2023.

Remote from Sacramento County

Responsibilities:

Manage day to day operations managed various multi-level clinical teams, of up to 24 RNs, LVNs, supervisors, leads and support staff, including Concurrent Review, Case Management, Retro Review, Post-claim Review and Provider Dispute Resolution.

Build skilled and collaborative team Hire, train and develop various teams to meet business needs, maintain regulatory compliance, promote staff retention and improve efficiency and productivity

Accountable for team quality. Ensured quality and compliance with standards, through case audits, metrics trending and training on identified areas with improvement needed. Participated in company-wide development of work process to drive quality and promote survey readiness. Actively participated in monthly quality meetings to drive improvement. Performed as a case presenter at NCQA surveys, DMHC and CDI audits, internal mock audits, and interrater reviews. Educated team on standards and provided team and individual status regularly.

Develop, monitor, and manage team and individual performance, from training to coaching to formal performance improvement plans, through frequent one to one meeting’s as well as informal check-ins, and structured and documented team meetings.

Develop and implement key work processes, and update annually.

Train for cross functioning, in both UM and CM, to meet business needs and ensure delivery

of appropriate, cost-effective services to plan members.

Actively participate in key Division and Organizational Committees, including but not limited to Employee Inclusion group for Veterans (2018 – 2023), maintaining SharePoint for networking sub-committee), Medical Management Competencies Development (2019-2023), New Manager training development (2019-2023), and various sprint groups for rapid change implementation (2020).

Facilitate ongoing collaboration and communication between UM Nurses/Case managers/ CCRNs and members, providers, HN Medical Directors and other stakeholders.

Optum (formerly Alere Health), 8/2007 – 6/2017, remote from CA. Multiple positions as below

Manager of Case Management (11/2011-6/2017)

Responsibilities:

Direct supervision of up to 21 RN Case managers, in various departments of the organization, performing in a case management environment across the continuum of care. Direct supervision of nurse performance of the systematic process, using a holistic approach, of complex case management for individuals with advanced oncology, Diabetes, COPD and/or catastrophic injury conditions.

Supervised performance of identification and engagement, enrollment, clinical assessment, care planning, care coordination (with physicians, hospital staff, medical group management and other healthcare providers), and the monitoring and promotion of appropriate health services utilization for quality cost-effective care, to promote access to care in a timely manner and patient/ family optimal health status.

Ensure compliance with clinical standards related to lab monitoring, medication compliance, care transitions, clinical indicators, pain and symptom management, resource finding, disease and self-management education and end of life issues.

Accountable for team quality. Performed as a case presenter at NCQA surveys, DMHC and CDI audits, internal mock audits, and interrater reviews. Promoted continuous quality improvement through staff education on standards, monitoring and reporting of team and individual status regularly. Conducted case audits, and implemented performance improvement measures as needed. Contributed to development of work process to drive quality and promote survey readiness.

Provide expertise regarding collaboration and counsel of patient and family members on correct benefit interpretation and utilization. Contribute to medical rounds to facilitate opportunities for cost-savings and quality of care improvements.

Motivate and develop direct reports, utilizing a team-centered approach, with routine monthly meetings to share and build upon collective expertise. Collect, trend, and analyze data to collaborate in program enhancement.

Track and report performance toward key metrics for organizational goals and client service level agreements. Monitor and maintain quality through performance of frequent call and documentation quality audits, perform coaching to elevate and maintain performance at expected levels, provide and document monthly feedback, document and deliver semi-annual and annual performance reviews. Perform monthly one to one meetings with each team member for coaching and development. Conduct hiring activities and training of new case management staff. Respond to patient and family complaints with follow through to resolution. Contribute to development, implementation and maintenance of department and organization level guidelines, work instructions, policies and procedures, as well as learning and development materials.

Contribute to Organizational Quality through participation in client meetings, documentation committee and inter-rater audits. Develop, prepare and deliver various staff presentations. Perform front line job in the field (see Catastrophic and complex care manager duty descriptions below) as needed to ensure timely and quality care to participants.

Catastrophic Case Manager (2/2010-12/2011)

Responsibilities:

Comprehensive complex case management for participants with burn, trauma, spinal cord and brain injury from intensive acute care to community based.

Execute clinical assessment, care planning, care coordination (with physicians, hospital staff, medical group management and other healthcare professionals), and utilization of resources/review of medical necessity, to promote cost effective care in a timely manner.

Within physician plan of care, assess participant status and needs and develop a patient-centered goal directed plan for meeting needs and care gaps.

In collaboration with health care team and patient/family, facilitate care plan progression from the acute level of care to appropriate level of care placement, including skilled care, long term care, assisted living and palliative/end of life care.

Utilize motivation interviewing techniques to promote behavior change for self-care. Conduct difficult end of life discussions with patient and families. Extract information in patient records and interpret results to facilitate needed care, facilitate diagnostic and laboratory testing as needed, provide condition/disease management education, and ensure appropriate plan for symptom management.

Facilitate timely scheduling of follow-up appointments; ensure compliance with clinical standards of care related to lab monitoring, medication compliance, care transitions, clinical indicators, pain and symptom management, resource finding, disease and self-management education; meet with patient and family in ICU and hospital setting, and again at each change of care level, to facilitate sensitive discussions surrounding options including end of life care, palliative care, rehab and long term care planning; facilitate advanced directives; coordinate comprehensive team conferences; intervene with education, care coordination, resource finding and facilitation of interdisciplinary health team communication.

Provide needed clinical information for client determinations, for patients in ICU, med-surg, acute rehab, post-acute care, home health and outpatient services. Evaluate impact of interventions on health outcomes directed at optimal health status, service utilization, and reduced ER and hospital admissions. Participated in multiple committees, and developed presentations and special projects, to promote clinical excellence of the staff.

Contributed to team quality by ensuring regulatory and NCQA standards met.

New Case Manager Preceptor (8/2009 – 12/2011)

Responsibilities:

Formally mentor new case managers on essential job functions, for a 60-day period, both in the field and remotely.

Train new staff to perform in-person initial assessment, execute thorough clinical documentation, develop and execute a care plan, and conduct resource finding.

Educate the new case manager on key clinical management points related to Diabetes, COPD, CAD, Asthma, as well as chronic pain and symptom-management.

Provide new hire education on various human resources processes.

Audit the home office.

Document progress toward the goals of the preceptor period, and communicate progress to the

employee’s direct supervisor.

Participate in training materials development.

Perform clinical quality audits and coach for improvement ensuring regulatory and NCQA accreditation standards met.

Complex Case Manager (8/2007 – 2/2010)

Responsibilities:

Care management of participants with complex, advanced oncology and co-morbid disease conditions, including Diabetes, COPD, CAD, Asthma and high-risk pregnancy, with goal directed care plan toward maximizing health status in least restrictive environment.

Execute clinical assessment, care planning, care coordination (with physicians, hospital staff, medical group management and other healthcare professionals), and monitor utilization of resources/review of medical necessity, to promote needed care in a timely manner. Systematically assess participant status and needs, develop a patient-centered goal directed plan for meeting needs and care gaps, and utilize motivation interviewing techniques to promote behavior change for self-care.

Extract information in patient records and interpret results to coordinate care and promote proper resource utilization; facilitate diagnostic and laboratory testing as needed; provide condition/disease management education;

Facilitate needed care with timely scheduling of follow-up appointments; promote patient/family communication with providers; ensure compliance with clinical standards of care related to lab monitoring, medication compliance, care transitions, clinical indicators, pain and symptom management, resource finding, disease and self-management education, and end of life issues.

Provide needed clinical information for client determinations.

Collaborate with key stakeholders to coordinate needed services, identify resources, educate on benefit utilization and facilitate communication on all fronts.

Systematically assess participant status and needs; facilitate advance directives; promote end of life discussion when appropriate; educate on alternate options including palliative care and long term care planning; intervene with education, care coordination, resource finding and facilitation of interdisciplinary health team communication; and evaluate impact of interventions on health outcomes directed at optimal health status, proper service utilization, reduced ER and hospital admissions. Participate in inter-rater audit and documentation committees to advance clinical excellence.

Maintain regulatory and accreditation standards compliance, including identification of knowledge gaps and self-learning.

Home Health Case Manager, 2000-2012, for multiple agencies including Santa Clarita Home Health, ABLE Home Health, and Care South

Responsibilities:

Full time case manager providing in-home nursing care and coordinating health care services for home bound individuals.

Systematically assess participant status and needs; facilitate advance directives; promote end of life discussion when appropriate; educate on alternate options including palliative care and long term care planning; intervene with education, care coordination, resource finding and facilitation of interdisciplinary health team communication; and evaluate impact of interventions on health outcomes directed at optimal health status, proper service utilization, reduced ER and hospital admissions.

Performed comprehensive initial assessment, nursing interventions, and patient self-care education, related but not limited to wound care and assessment, IV infusion therapy, PICC line care, port-a-cath care, enteral feedings, administration of IM and SQ medications, placement and irrigation of indwelling urinary catheters, colostomy maintenance, and vital health measurement performance and monitoring.

Educated on various health conditions and self-care implications, including but not limited to Diabetes, CHF, CAD, COPD, and end-of-life care. Promoted advanced directives, end-of-life discussions and long term planning.

AFFILIATIONS

2007 - present CMSA

2007 - present Sigma Theta Tau International

2000 - 2007 CSUN Nursing Honor Society

2000 - present CSUN RNBSN Alumni Chapter, founder in 2000

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