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Case Management

Location:
Menifee, CA
Salary:
95000
Posted:
April 27, 2020

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Resume:

Registered Nurse, Case Management

Qualifications Profile

Adept in complex case management and patient-centered care and expert in handling diverse cases including chronic conditions, polypharmacy, behavioral health, and catastrophic illness.

Core Competencies

Program Development Regulatory Compliance Patient Relations and Education Case Assessment

Information Management and Analysis Strategic Planning and Execution Personnel Training and Guidance

Professional Experience

Centene Woodland Hills, CA

Clinical Compliance Auditor Nov 2019–Present

Direct compliance audits of vendors as well as determine audit scope and required audit tools

Monitor the appropriate compilation and management of audit results within designated audit tools

Take charge of overseeing, auditing, and monitoring both internal and external vendors against CMS, contractual, Federal, State, and NCQA standards

Conduct thorough assessment of vendors documented processes against contractual, Federal, State, CMS, and NCQA standards

Determine the process gaps and deficiencies as well as relay the audit observations, recommendations, and process improvement opportunities

Perform direct establishment of quality improvement and corrective action plans based on risk analysis, audit findings, and vendor performance

Develop audit tools based on contracted services with vendors and requirements defined by CMS, State, Federal, Medicaid and/or NCQA guidelines

Maintain documentation on vendor performance and provide reports to subsidiaries as required for audits and risk assessments. Lead vendor performance oversight meetings with impacted business owners and vendors

Blue Shield of California Rancho Cordova, CA

Clinical Educator Consultant Sep 2018–Nov 2019

Conducted audit and performance assessment of medical management nurses

Ensured consistent compliance with California continuing education provider requirements as well as with URAC, National Committee for Quality Assurance (NCQA), and Department of Managed Health Care (DMHC) training standards

Served as a resource to staff, responsible for providing assistance in resolving complex case issues and interpreting departmental protocols and procedures

Exemplified strong leadership skills through employment of motivational interviewing theory and practice, while ensuring effective coaching of staff on the department’s best practices

Drove clinical staff development through improvement of processes, maintenance of compliance, and execution of quality training programs

Effectively addressed all clinical needs by establishing and enhancing the audit criteria and training courses and programs

Triage/Complex Case Manager Sep 2012–Sep 2018

Offered outstanding services to the members of Blue Shield of California, including outreach and care coordination as well as complex case management while exhibiting exceptional clinical judgment and member collaboration

Demonstrated excellent knowledge of evidenced-based clinical practice guidelines of chronic conditions

Filled the gaps in care through effective utilization of community resources

Acquired and maintained Commission for Case Manager (CCM) certification through practice and continuing education

Promoted quality cost-effective care based on the patient’s needs by researching and creating treatment and care plans

Provided direct help with discharge planning for medically complex cases, as well as appropriate referrals to disease management and partners in care (community resources support) and palliative care programs

Applied effective motivational interviewing techniques in assessing the health behaviors of all members as well as their cultural influences and belief systems

Boosted member engagement and guarantee improvement of patient care outcomes by anticipating all the potential barriers to care and leading targeted interventions

Rehabilitation Care/ Sutter Roseville Hospital, Sacramento, CA

Case Manager Dec 2010–Sep 2012

Carried out program development and clinical assessment while collaborating with case managers and discharge planners

Facilitated program development activities within the community, which included healthcare providers and managed care organizations

Led various onsite clinical evaluations and conducted collection of potential patients’ information prior to admission into the acute rehabilitation facility

Assessed all ventilator patients in the intensive care and coronary care units

Drafted clinical documents for admission review of the medical director to admitting physician

Worked with provider relations to verify funding and authorizations

Earlier Positions Held:

University Retirement Community, Davis, CA

Wellness Director Jul 2007–Jun 2009

Courtyard Healthcare Center, Davis, CA

Director of Staff Development Nov 2006–Jul 2007

Prime Career College, Sacramento, CA

Instructor Feb 2004–Jun 2006

Sunrise Assisted Living, Fair Oaks, CA

Resident Services Coordinator Feb 2003–Feb 2004

Aegis of Carmichael, Carmichael, CA

Wellness Nurse Apr 2001–Feb 2003

Eskaton Village, Carmichael, CA

Licensed Practical Vocational Nurse/Charge Nurse Aug 2000–May 2001

Sutter Roseville Medical Center, Roseville, CA

Licensed Vocational Nurse Jun 1999–Jul 2001

Brittany Healthcare, Carmichael, CA

Restorative Nurse Assistant May 1993–Aug 1994

Mercy General Hospital, Sacramento, CA Walnut Whitney Convalescent, Carmichael, CA

Certified Nursing Assistant 1991– 1997

Education

Master of Science in Nursing Education, 2012

University of Phoenix, Salida, CA

Bachelor of Science in Nursing, 2010

University of Phoenix, Salida, CA

Professional Development

Certification

Case Management Certification, 2016

California Public Health Certificate, 2010

Cardiopulmonary Resuscitation (CPR) Instructor, 2008

License

California Vocational Nurse License

Training

Regional Occupational Program, Health Ancillary Training Services (HATS), Sacramento, CA

Nurse Assistant Training Program, Walnut Whitney Convalescent, Carmichael, CA

Activities

Program Counsel, University of Phoenix

Member, Sigma Theta Tau International



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