Medical Nurse
Resume:
Wendy Pitts, MSN, MBA, RN, CCM
Lutz, FL 33558
************@*****.***
PROFILE & KEY ACCOMPLISHMENTS
Highly organized, results driven professional, with unrivaled team building capabilities. Possesses outstanding communication and analytical skills, and a dynamic capability to successfully lead a large and complex department, in a results-driven business environment. Key strength includes capability to quickly assess, plan, and implement division-wide change, when required to support critical business initiatives. Background includes: Director level experience in Medicare and Medicaid lines of business, and, at a major urban University Medical Center – in this capacity, achieved a two-day LOS reduction within a six month time frame. Extensive program implementation experience, for both new and existing clients, within Managed Care Operations. Broad vendor implementation and vendor management expertise. Diverse background, including: Managed Care Operations executive leadership; Government Programs; Project Management; Certified Case Manager; support staff for underwriting; critical care; pediatrics; medical/surgical; private duty nursing; and, charge nurse experience. Current RN licensure in Illinois and Tennessee (multistate).
EXPERIENCE
WellCare/Centene Corporation, Tampa, FL: 2019 – present
Title: Senior Director, Case Management
Responsibilities:
• Primary oversight and accountability for clinical operations in pediatric field case management.
• Strategize, coordinate, and implement clinical programs and solutions, while maximizing departmental efficiencies, emphasizing flexibility in a rapidly evolving marketplace.
• Develop new clinical and administrative initiatives to positively impact medical cost trend.
• Achieve continuous improvement of operational and financial performance, supporting a strong competitive position.
• Establish and monitor operational performance metric targets in collaboration with the medical management team, including medical directors, pharmacy directors and external vendors.
• Serve as enterprise-wide subject matter expert on health services delivery; interface cross-functionally, at all levels of the organization, ensuring program/service delivery to internal/external stakeholders.
• Integrate with medical directors performing medical management consultations, to ensure consistent and timely reviews and appeals.
• Ensure all programs and processes meet requirements of CMS regulations, as well as URAC and NCQA standards, and direct required quality improvement activities.
• Provide primary leadership on various corporate committees and enterprise-wide projects affecting clinical staff.
• Identify and lead implementation of measurable continuous quality improvements for department, including impact analysis to measure return on investment (ROI).
• Support and protect our competitive position in the marketplace, while maintaining regulatory requirements.
• Frequently serve as primary leader in the absence of Vice President of Medical Management.
BlueCross BlueShield of Tennessee, Chattanooga TN: 2018 – 2019
Title: Director, Health Services, Medicare Advantage Plan
Responsibilities:
• Primary oversight and accountability for clinical operations, including utilization management and case management, for the Senior Products division.
• Strategize, coordinate, and implement clinical programs and solutions, while maximizing departmental efficiencies, emphasizing flexibility in a rapidly evolving marketplace.
• Develop new clinical and administrative initiatives to positively impact medical cost trend.
• Achieve continuous improvement of operational and financial performance, supporting a strong competitive position.
• Establish and monitor operational performance metric targets in collaboration with the medical management team, including medical directors, pharmacy directors and external vendors.
• Serve as enterprise-wide subject matter expert on health services delivery; interface cross-functionally, at all levels of the organization, ensuring program/service delivery to internal/external stakeholders.
• Integrate with medical directors performing medical management consultations, to ensure consistent and timely reviews and appeals.
• Ensure all programs and processes meet requirements of CMS regulations, as well as URAC and NCQA standards, and direct required quality improvement activities.
• Provide primary leadership on various corporate committees and enterprise-wide projects affecting clinical staff, such as, but not limited to, interfacing with gain share groups/value based program initiatives.
• Identify and lead implementation of measurable continuous quality improvements for department, including impact analysis to measure return on investment (ROI).
• Support and protect our competitive position in the marketplace, while maintaining regulatory requirements.
• Serve as primary leader in the absence of Vice President of Medical Management for Senior Care Division.
University of Chicago Medical Center, Chicago IL: 2015 – 2018
Title: Director, Case Management & Utilization Management
Responsibilities:
• Provide oversight and direction to the Case Management and Utilization Management departments, encompassing care within an 800-bed hospital, including: Adult; Pediatrics; and, Emergency Departments.
• Identify appropriate staffing levels, assignments and deployments for the department.
• Monitor performance criteria for staff members.
• Implement and review operations of the Case Management department, to ensure high level of quality, consistent with organization standards.
• Implement and review department performance in relation to established goals.
• Implement changes to effect continual improvement in services provided.
• Interprets laws, policies, operational procedures and objectives, and ensure compliance with regulatory and legal requirements.
• Collect, analyze, evaluate, and present clinical management and operations data to a wide range of internal and external audiences.
• Develop a comprehensive safety/quality and performance improvement program, inclusive of the analysis and trending of data related to initiatives undertaken.
• Work closely with physician leadership at the C-suite level, including clinical department chairs and committee chairs, to ensure appropriate medical staff involvement in institutional resource management efforts.
• Participate with assigned medical staff, executive and corporate committees, to promote effective communication between departments, acting as a liaison to facilitate information sharing, collaborative problem solving and adequate provision of support services.
• Foster and maintain collaborative relationships within the Health System, and with external agencies related to quality and performance initiatives, as well as daily operational issues that may arise.
• Responsible for personnel actions including, but not limited to, hiring, performance appraisals, promotions, vacation schedules, and maintaining payroll records, employee engagement trends, and time reports.
• Collaborate with administration, management and educational resources to develop mechanisms for staff development and to make appropriate changes as needed to keep department current with new regulations, policies and trends in the Case Management field.
• In collaboration with the Vice President of Risk Management, participate in the preparation of department budget, and make budgetary recommendations and projections.
• Manage clinical services, including oversight of clinical policies and procedures, day-to-day clinical services and staff.
• Ensure compliance with established initial and concurrent review, case management, referral, pre-certification and authorization policies, procedures and processes.
IliniCare Health Plan/Centene Corporation, Westmont IL: 2014 – 2015
Title: Clinical Manager, Case Management
Responsibilities:
• Manage clinical services, including oversight of clinical policies and procedures, day-to-day clinical services and staff.
• Ensure compliance with established initial and concurrent review, case management, referral, pre-certification and authorization policies, procedures and processes.
• Ensure all programs and clinical operations are in full compliance with state and federal regulations.
• Ensure compliance with plan’s emergency management policies, procedures and processes by acting as liaison with other business units.
• Ensure payer contract clinical deliverables are met.
• Monitor the effectiveness of existing procedures and outreach/intervention efforts.
• Ensure appropriate knowledge/education and interventions are conducted for members defined to be at risk.
• Monitor data to address trends or potential quality improvement opportunities including provider issues, service gaps, member needs.
• Management of staff, including but not limited to: hiring, training and mentoring, team goal management, performance management, pay administration, budget, professional development, diversity, and change management.
• Ensure strict adherence to Interqual, HIPAA, NCQA, and HEDIS policies and guidelines.
Health Care Service Corporation (BCBSIL) Chicago, IL: 2008 – 2014
Title: Senior Manager, Clinical Operations, Case Management
Responsibilities:
• Staff management and support, including but not limited to: hiring, training and mentoring, team goal management, performance management, pay administration, budget, professional development, diversity, and change management.
• Management of business relationships and communication with key stakeholders, such as corporate representatives from: large national accounts; national consulting firms; senior leadership (VP level).
• Lead implementation activities for new clinical programs, at the large national account level.
• Function as the business lead in development and integration of new clinical programs, with duties including: preparation of project plans; organizing and instructing the project team; and, evaluating results.
• Lead, develop, implement, and evaluate readiness assessment requirement plans for large national accounts and the mid-sized market segment.
• Identify and recommend system enhancements, to support effective administration of CM programs.
• Participate in the development of strategies and objectives for operating procedures, department efficiencies, and enhanced cost containment programs, to ensure effective departmental performance monitoring and control.
• Facilitate ongoing evaluation of care management program operations, including identification and implementation of best practice recommendations.
• Collaborate with appropriate departments to interpret benefits, contract requirements, reimbursement issues, reporting requirements, and to develop effective implementation strategies.
• Maintain current knowledge and compliance with all applicable regulatory and accreditation standards.
• Provide Clinical Operations representation at meetings, conventions, and seminars, designed to advance managed care effectiveness.
• Ensure effective and appropriate interface with internal divisions and external entities, to enhance corporate cost containment efforts, and positively influence the community’s perception of our organization.
• Succinctly represent our programs and policies to internal and external entities.
• Participate in preparation of assigned annual budget, with adherence to corporate guidelines.
Paradise Park Assisted Living and Memory Care, New Lenox IL: 2007 - 2008
Title: Director of Nursing
Responsibilities:
• Develop, maintain, and implement nursing policies and procedures that conform to current standards of nursing practice, facility philosophy, and operational policies while maintaining compliance with state and federal laws and regulations.
• Management of staff, including but not limited to: hiring, training and mentoring, team goal management, performance management, pay administration, budget, professional development, diversity, and change management.
• Participates in all admission decisions, and, may visit prospective residents before admission.
• Ensure delivery of compassionate quality care and nursing supervision, as evidenced by adequate services and staff coverage on unit and apparent maintenance of optimal resident functions.
• Provide oversight to ensure that all resident health records are complete, including overall supervision of resident assessments and care plans.
• Implement employee training programs.
• Evaluates the work performance of all nursing personnel, assists in the determination of wage increases, and implements discipline according to operational policies.
• Chair and lead weekly management team meetings to discuss resident status, census changes, personnel, or resident complaints or concerns.
• Collaborate with physicians, consultants, community agencies, and institutions, to improve the quality of resident services and to resolve identified problems.
• Serve as Quality Assurance team manager.
• Maintain appropriate employee file documentation, including all employee health files.
• Manage all terminated employee files, including proper communication with IL Department of Unemployment Security, serving as point person for unemployment hearings.
• Conduct routine CPR certification classes for regional locations.
• Direct and manage communication with pharmacy, ensuring that all drugs, and supplies reach facility accurately, and in a timely manner.
Advocate Christ Medical Center, Oak Lawn IL: 2006 – 2007
Title: Staff Nurse (Medical/Surgical and MICCU)
Responsibilities:
• Identify patient care requirements by establishing personal rapport with patients, family members, and other persons in a position to understand care requirements.
• Establish a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families.
• Promote patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills.
• Assure quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations.
• Resolve patient problems and needs by utilizing multidisciplinary team strategies.
• Maintain safe working environment by complying with procedures, rules, and regulations; calling for assistance from health care support personnel.
• Document patient care services by charting in patient and department records, while maintaining strict confidentiality.
• Maintain continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs.
• Cultivate a collaborative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem-solving methods.
RSA Medical, Naperville IL: 2004 – 2007
Title: Staff Nurse (Clinical Support Staff – Underwriting Department)
Responsibilities:
• Interview patients regarding their health history.
• Document and communicate detailed medical information to underwriting for determination of patients’ eligibility for life, health, and disability insurance policies with national insurers.
• Train new employees to ensure their competency in the patient interview process.
• Supported in the development and implementation of new workflow process for transfer of live calls to nursing department.
• RSA Medical is a privately held company that performs contract work for HCSC, for the individual market, as well as Government Programs.
Total Nurses Network, Oak Park IL: 2003 – 2007
Title: Staff Nurse
Responsibilities:
• Report for duty on an on-call, as needed basis to local area skilled nursing care facilities.
• Perform floor nurse duties as assigned by each facility including: medication administration, treatments, communication with patient physicians, and proper documentation per procedure, etc.
American Home Health, Aurora, IL: 2000 – 2004
Title: Staff Nurse
Responsibilities:
• Primary care of pediatric patient cases including care of tracheotomy/ventilator dependent patients.
• Clinical and case management documentation of patient records.
• Train and mentor less experienced staff nurses; and, evaluation of peers' progress.
EDUCATION
Master of Science in Nursing
University of South Carolina, Columbia, SC
Master of Business Administration
Lake Forest Graduate School of Management, Lake Forest, IL
Bachelor of Science in Nursing
Liberty University, Lynchburg, VA
Associate of Science in Nursing
Joliet Junior College, Joliet, IL
Licensed Practical Nurse
Joliet Township School of Practical Nursing, Joliet, IL
SKILLS
• Proficient in the following programs:
-EPIC
-Medecision/Aerial
-TruCare
-CareAdvance
-MCG
-InterQual
-MediTech
-People Soft
-Oracle
-Tableau
-Concur
-WorkDay
-Kronos
-WebEx
-Microsoft Office Suite
-iWorks
• Served on Board of Directors: President Elect – CMSA, Chattanooga Chapter (Case Management Society of America)
• CCM (Certified Case Manager)
• Recent ACLS Certification (exp. 12/2018)
• Extensive LEAN/Six Sigma participation
• Presenter, Alzheimer's Association Dementia Capable Training Video (Presenter Specialty: Managed Care Organizations, Supporting Persons Living With Dementia)
• Completed Project Management Certificate Program, Loyola University
• Member, Sigma Theta Tau International Honor Society of Nursing
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