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Director of Health Services

Location:
San Diego, CA
Posted:
January 11, 2021

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Resume:

Lavinia Y. Smith

423-***-**** (Cell)

E-mail: adjcke@r.postjobfree.com

Professional Summary: Nursing Director with over 28 years of intensive acute and long-term Health plan implementation experience to include: Utilization Management, Integrated Case

Management, Behavioral Health, Appeals and Denials, Revenue Cycle, State & Federal Compliance, HEDIS, NCQA, URAQ Accreditation, Quality, Specializing in facility or program reorganization.

Education:

2017- 2021 East Carolina University

Greenville, NC

MSN- DNP

2006-2008 Carson Newman College

Jefferson City, TN

BSN, 2008 – Cum Laude- Dean's List 2006-08

Experience:

October 2019 - Present Director of Case Management Community Health Group, San Diego, CA

● Provides direct supervision for 40+ Clinical and Non-Clinical staff (RNs, IMGs, HRA Outreach Specialists, Health Educator and Non-Clinical Staff)

● Maintains Accountability to ensure Case Management Department and Health Education Programs meet contractual requirements set forth by CMS, DHCS and DMHC while supporting initiatives with our Providers, Value Based Partners and members to manage cost of care.

● Directs Oversight and development of new and existing contractual changes around Enhanced Case Management and Quality of Care for all CMC and MediCal membership to include: Requests for Procurement, contracts, policies, procedures, workflows and process improvements related to Case Management.

● Manages, trains, develops and motivates case management and care coordination staff to accomplish program goals and objectives.

● Decreases readmission rates by implementing ER Diversion Programs and Initiatives that impact Social Determinants of Health with primary focus on Homelessness or members at risk.

● Develops and implements process improvements to ensure compliance with all state and federal regulatory requirements. January 2018 – October 2019 Health Services Director – WellCare Arizona Market (Medicare & Arizona Medicaid)

● Provided direct supervision for 75+ Care Coordination, Telephonic & Field Care Management, Utilization Management & Appeals staff. (RNs, LCSWs, LPCs, BH Specialists & BH MSWs)

● Maintained Accountability for Medical Management and ensured Utilization Management, Prior Authorization, Care Management and Appeals departments met the contractual requirements set forth by state and federal agencies while supporting initiatives with our Providers, Value Based Partners and members to manage cost of care.

● Direct Oversight and development of new and existing contractual changes around Integrated Medical Management, Quality of Care and Member Services departments. To include: Requests for Procurement, contracts, policies, procedures and workflows.

● Collaborated with Quality & Compliance leadership to develop audit tools to ensure MM department was actively supporting KPIs, QAIs, HEDIS and STAR Measures daily while maintaining 100% Member and Provider satisfaction scores.

● Improved efficiency and the effectiveness of delivery of care by initiating internal programs that have decreased hospital readmission by 37%, ER Utilization by 17%, decreased TAT by 12% and increased CM enrollment & engagement by 30% within 3 months.

● Collected, Analyzed and Prepared monthly, quarterly annual reports to measure all Utilization, Prior Authorization, Appeals and Care Management information to determine efficiency, effectiveness and quality of all managed care services being provided to the membership population and providers.

● Conducted ongoing monitoring of Quality of Care provided by staff, network providers, vendors and Value Based Partners reporting back to state and local agencies. Ensured monitoring and tracking tools were in place to adequately link and assess production and quality driven work products and outcomes to individual performers.

● Participated in monthly financial oversight with local and national leaders including Quality Improvement, Analytics, Corporate finance, network and other areas to ensure a comprehensive approach to managing quality of care, service and cost of care.

● Responsible for conflict/concern resolution and communication of UM, CM and Member Service issues reported by members, state or federal agencies to the health plan. Information obtained is used for coaching and or corrective action plan activities and reporting.

● Served as Subject Matter Expert for: Integrated Care Management Model of care providing comprehensive assessments ensuring inclusion of SDOH and Member/Provider/Specialist participation in ICP development, evaluation of the UM Department’s usage of criteria-based reviews of care and Clinical Appeals usage of Medical Necessity Reviews including members.

● Lead and Developed the ongoing evaluation tools for process development & enhancements, staff performance, leadership development plans and training programs for all Utilization and Care Management department & staff.

● Engaged in chair/ co-chair and board membership with Utilization & Care Management Committees, AHCCCS Quality Insurance Committee, Arizona Member Advocacy Councils, CASQUIC, PMC, CMS QIC and Member/ Provider Engagement Committee at both the local, state and federal levels.

June 2017 – December 2018 Texas Children’s Hospital, Houston, Texas Heart Center Department Interim Manager of Care Management

● Planned and executed interdisciplinary and patient/family conferences as necessary to formulate and communicate the plan of care for all five cardiac departments.

● Initiated and implemented plan modifications during the episode of hospitalization and for post-acute care through monitoring and re- evaluation to accommodate changes in treatment or progress.

● Anticipated potential variances in the plan of care process and incorporates contingency plans for each step in the process to offset treatment & service delays.

● Effectively monitored patient flow data for all five cardiac pavilions. Proactively identified, arranged, and modified all cardiac patient flow throughout the cardiac pavilions.

● Maintained responsibility for the assessment, coordination, staffing and education regarding options for care and available resources for all International and Cardiac Transplant patients.

● Developed Utilization Management platform & Interrater Reliability Tools that supported Milliman & MCG Guidelines. Trained 65 staff to use guidelines and tools with 99% monthly audit scores maintained for 12 mos.

● Identified actual and potential problems in services and treatments. Leads multidisciplinary team discussions for resolution.

● Provided ongoing education to members of the interdisciplinary team regarding pertinent aspects of Care Management including but not limited to utilization management, care coordination, transition/discharge planning, and psycho-social patient needs.

October 2008- March 2017. - United Healthcare Community and State, Sugarland, Texas Health Service Director- Community and State (2015 – 2017)

● Provided direct supervision of Registered Nurses, Licensed Practical Nurses, Licensed Social Workers providing service coordination and an administrative staff providing support to clinical staff, ensuring state deliverables & productivity goals are met with regards to quality, timeliness, accuracy, and consistency making decisions for more than 30,000 Texas STAR Kids medically fragile children receiving waiver & LTSS services along with an additional 100, 000 level II & III children.

● Created and monitored all reports for state deliverables for Health Human Services and Department of Aging and Disabilities to include all HEDIS.

● Communicated information to state and federal legislature on behalf of Texas medically fragile children and children with intellectual & developmental disabilities.

● Coordinated regulatory, quality and accreditation activities within the entire Children’s Programs to include all Texas waivers: Medically Dependent Children program, Intellectual & Developmentally Disabled

(CLASS, HCS, TxHML, DBMD & YES waivers) and medically complex children on SSI.

● Developed and implemented all policies and procedures for all levels of care for the medically fragile children throughout the entire state of Texas.

● Developed and Implemented all training programs for the medically complex children on SSI, Medically Dependent Children’s Program, Intellectual & Developmental Disabled, Field and Telephonic Service Coordination teams.

● Implemented and recommends departmental policies and procedures, and interfaces with compliance to ensure consistent applications within UM, CM and PA departments.

● Interfaced with state regulatory agencies, plan medical director, local authorities & agencies, members and providers.

● Participated in quality engagement sessions with HHSC, MHMR, DADs, NCQA and URAC.

Health Service Manager – Texas Community and State (2013- 2015)

● Provided direct supervision of Registered Nurses, Licensed Practical Nurses and Licensed Social Workers to ensure productivity goals are met with regards to quality, timeliness, accuracy, and consistency making decisions for possible PHC Services.

● Developed and Monitored required metric goals for staff as well as provided ongoing feedback and coaching to provide outstanding service to members.

● Communicated complex information and interacts through use of electronic documentation utilizing a variety of charting systems.

● Coordinated regulatory, quality and accreditation activities within the team to ensure state and federal compliance.

● Developed and implemented processes to assess staff for inter-rater reliability; identify areas for improvement and implements training and/ or process changes as needed.

● Developed and implemented training plans for the Texas SP IDD team and educated other teams on the IDD process.

● Implements and recommends departmental policies and procedures, and interfaces with other HSM’s to ensure consistent applications.

● Interfaced with state regulatory agencies, plan medical director, local authorities & agencies, members and providers.

● Participated in quality engagement sessions with HHSC, MMHR & plan

● Developed and Monitored over/under Utilization Acute and Post Acute Supervisor Utilization Management & Clinical Trainer (2008-2013) – Arizona

● Provided direct supervision of Registered Nurses, Licensed Practical Nurses and Service Coordinators teams up to 150 to ensure productivity goals are met with regards to quality, timeliness, accuracy, and consistency of medical decisions.

● Provided direct oversight for the provision of day-to-day Medical Management functions which include: Pre-Certification, Concurrent Review, and Discharge Planning for Inpatient and Outpatient UM teams.

● Communicated complex information and interacts through use of electronic documentation utilizing a variety of charting systems.

● Developed and Monitored goals for staff as well as provides ongoing feedback and coaching.

● Developed and implemented maternal child programs for high risk pregnancies and complex case development. To include: Health plan implementation, staff training, long-term analysis of future Maternal Child Development Programs with Medicaid, Medicare and Commercial programs within the Health plan.

● Developed UM training plan to ensure new and existing staff have the knowledge and skills to competently perform their job function. To include criteria based programs: Interqual, Milliman, Interqual and MCG.

● Developed UM work plan with deliverables and timelines; managed dept. within the structure of the work plan.

● Coordinated regulatory, quality and accreditation activities within the team.

● Implemented and recommends departmental policies and procedures, and interfaces with other areas to ensure consistent applications.

● Interfaced directly with the plans medical directors, DME’s, community programs, hospitals and skilled nursing facilities to ensure coordinated, continuous cost-effective quality healthcare for our members.

● Participated in quality improvement process team; track and report trends of inappropriate utilization of resources, readmission risks and over-utilization of services.

December 2010- 2012 – Yuma Regional Medical Center, Yuma, AZ 85364 Registered Nurse Case Manager Maternal Child / Utilization Review Nurse Weekend Supervisor

● Supervised Utilization Review and Case Management staff of 30-50, Staff Nurses, Case Managers and 20-25 concurrent review staff. To include: scheduling and staffing, PTO approvals, IRR, SOX and yearly performance reviews.

● Trained clinical staff and UR nurses utilizing both Milliman and InterQual programs. Also, electronic charting systems to include: Epic, Chartmaxx, Cerner, Meditech Allscripts, McKesson, GE Healthcare, Care 360 and ADP Advancedmd.

● Predicted and planned needs from pre-admission, through acute, sub- acute, care and post discharge.

● Assessed inpatient census for appropriate alternative health care service needs.

● Reviewed health plan appeal items for concurrent and retrospective reviews prior to State Fair Hearings and OFR. Attended all 1st, 2nd and FH appeals.

● Managed patient discharge referrals to Home Health Agencies, Rehab facilities, Skilled Nursing Facilities, Long-term Nursing facilities and mental health facilities.

May 1989-May 2008 U.S Army, FSH, San Antonio, TX

Medivac/Trauma/Urology/Military Nurse Instructor

● Assisted in procedures to include: IVP, VCUG, cystoscopy, vasectomies, adult circumcisions, nephrectomies, and kidney transplants

● Instructor for Medic Training Program, Expert Field Medical Course and Adult and Pediatric Advanced Life Support

● Drill Sgt- Instructed troops in leadership, basic field medical courses, physical training and basic rifle marksmanship. (up to 400 soldiers)

● Nursing Program Cadre- Instructed LPN & RN Medical, Surgical & Trauma Rotations

Professional Organizations: NCNA Informatics and Practice Council, CCMC- AZ, CASQUIC, NAMI, SAMSA and CMS QAI

Certifications: BCLS, ACLS, NRP, PALS, NCC-RNC, CMCN, CCM



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