Manager Care
Resume:
PAUL
GULLETT
**** ****** **** **, ******, OH ***20, 740-***-****, *********@*******.***
PROFESSIONAL SUMMARY
An accomplished and trustworthy leader in clinical services with a talent for nursing team development, case management, utilization management and healthcare quality improvements. Takes ownership for complex procedures and develops tools to guide staff learning and development. Displays strong communication skills, excels at time management and effectively balances a high-capacity workload with team leadership.
SKILLS
RN, MSN, MBA
Utilization Management
Quality Improvement and Management
Case Management
Clinical Leadership
Quality Med Surg/Tele Nurse Charge Nurse
URAC Knowledgeable
Oncology/Stepdown charge nurse
NCQA management
JACHO Knowledgeable
CMS Knowledgeable
Ortho knowledgeable
EXPERIENCE
RN AGENCY NURSE
BLESSED HEALTHCARE STAFFING Columbus, OH
March 2012 - Current
Hired by Parkland Hospital, UT Southwestern, Advocate Health, and Amita Health to work Med surg, Telemetry, Ortho, Infectious diseases, oncology, step down floors and provide care to low income, homeless and immigrant patient populations. Mostly did charge nursing at these sites as well.
• Improved the quality and service techniques for handling highly communicable diseases such as HIV, tuberculosis, mononucleosis and adult chicken pox.
• Influenced the new Nursing Manager to adjust the supply budget allocations and resolved shortages in medical supplies. Secured adequate IV bags, IV start kits and pumps to meet patient demand.
• Proposed room layout concepts to contractors of the hospital facility under construction and improved nurse access to IV equipment, oxygen and expansion areas. Recommendations were fully accepted and implemented in the final hospital design. Increased staff effectiveness and directly improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.
• Joined the floor rotation and provided consistent support to physicians and patients including initial patient assessment, IV hydration, medication administration, blood draws and Lasix therapy.
• Promoted to assistant manager because of quality and time management; hired new staff, managed the labor/floor budget and handled patient census and safety reports, ordered supplies
• Improved patient satisfaction scores for nursing communication to above the national average of 76% and earned praise from the Vice President of Nursing.
• Improved length of stays through the hospital with plan of working with providers.
• 3-1 ratios for step down up to 6-1 on med surg. Responsible for assessing a patients need and readiness for being discharged to home. Does complete care on patients. Rounds with Doctors and works as interdisciplinary team. Services include Orthopedic rehabilitation, Multiple trauma care, Cardiovascular rehabilitation, Stroke rehabilitation, Amputee rehabilitation, Pulmonary rehabilitation, Respiratory rehabilitation, Neuromuscular
disorders, Wound management, Diabetic management., tube feeds, colostomies and drips are very common
RN MANAGER/DIRECTOR OF UTILIZATION MANAGEMENT
AIm Specialty Health Deerfield, IL
November 2018 -May 2020
• Hired to manage a team of case managers and clinical review processors in solution management and providing many different case managements, utilization management, and disease management to clients, health insurance companies, hospitals, SNF's, and Providers. Worked with members, providers, federal and state agencies, and multidisciplinary teams to assess, plan and coordinated an integrated delivery of health care across the continuum of care. Trying to expand operations into new states and additional markets, it aims to take concrete steps to comply with the ever-dynamic market regulations. The CMS and States Liaisons Unit works in sync with Compliance team to oversee the implementation of new regulations, ensure overall regulatory compliance, and maintain accountability for relationships with key CMS and regulatory agency stakeholders.
• Solutions include Radiology Benefit Management, Radiation Oncology, Special Pharmacy, Rehab, Musculoskeletal, Ingenio RX, Oncology, Genetics, Specialty Shopper program, and others that are requested by the clients
• Utilized Model Of Care for CMS and educated, trained, many employees on all aspects of CMS requirements and was a leader through the CMS audit Process
• Utilized NCQA standards for Medicaid, and Medicare members and educated, trained, many employees on all aspects of NCQA requirements and was a leader through the NCQA audit Process.
• Functioned as a hands-on supervisor, providing direction and guidance to the care management team, utilization management team, and disease management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements.
• Managed staff caseloads and assigns cases appropriately with regard to complexity of medical or psychosocial needs and case manager experience (L MSW, other allied fields).
• Oversee the staff use of the electronic case management and utilization management [support coordination] documentation system in compliance with standard ICA processes, standard documentation styles, and HIPAA. Arranged training as needed.
• Managed, coached and evaluated the performance of team members; provided employee development and recognition; and assists with selection, orientation and mentoring of new staff.
• Promoted multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina duals and star plus members.
• Worked with the Director to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators
RN INTERIM MANAGER OF SERVICE COORDINATION
Superior Health Plan Dallas, TX
April 2018 - November 2018
• Oversaw a Care Management team responsible for supports coordination, community resources, health management, and/or transition of care activities to assist Dual, Medicare, Medicaid and marketplace members with their behavioral and physical healthcare needs.
• Supported Management staff work to help members achieve optimal clinical, financial and quality of life outcomes, including safely and effectively transitioning Dual and Star Plus and marketplace members from acute or inpatient care to lower levels of care and/or home in a cost-efficient manner.
• Functioned as a hands-on supervisor, providing direction and guidance to the care management team, utilization management team, and disease management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements.
• Managed staff caseloads and assigns cases appropriately with regard to complexity of medical or psychosocial needs and case manager experience (L MSW, other allied fields).
• Oversee the staff use of the electronic case management and utilization management [support coordination] documentation system in compliance with standard ICA processes, standard documentation styles, and HIPAA. Arranged training as needed.
• Managed, coached and evaluated the performance of team members; provided employee development and recognition; and assists with selection, orientation and mentoring of new staff.
• Promoted multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina duals and star plus members.
• Worked with the Director to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Audited case management [supports coordination] assessments and care [individual plan of service] development for completeness and timeliness according to state requirements as well as utilization management productivity numbers and process implementation.
• Monitored onsite hospital discharge visits and post-discharge visits to assure continuity of care and prevent unnecessary readmissions.
• Monitored the completeness of the Transition of Care (ToC) assessment and the timeframes for contact are per ToC protocols.
• Utilized Model Of Care for CMS and educated, trained, many employees on all aspects of CMS requirements and was a leader through the CMS audit Process
• Utilized NCQA standards for Medicaid, and Medicare members and educated, trained, many employees on all aspects of NCQA requirements and was a leader through the NCQA audit Process.
RN INTERIM PROGRAM COORDINATOR
Cooks Children Hospital Fort Worth, TX
December 2017 - April 2018
• Hired to manage a team of Clinical Review Processors, Clinical Review Clinicians, Case Managers and Licensed Practical Nurses tasked with implementing processes of commercial insurance, Medicare, Medicaid population. Management of RN Case Managers Run the day to day duties for my RN's payroll, budgeting, education, and building processes for direct reports. Implementing guiding principles, processes for the hospital, home health, and health plan. Following accreditation standards of NCQA, HCHAPS, and other regulatory agencies. Provide oversight as an expert to get the health system combined in the positive direction. Establish policies for all case managers, utilization managers, disease case managers, home health case managers, complex case management and educate staff on the policies. Currently building the UM policies for the health plan as well as the denials and appeals team being developed to effectively manage denials, fair hearings, and appeals.
• Oversaw a Care Management team responsible for supports coordination, community resources, health management, and/or transition of care activities to assist Dual, Medicare, Medicaid and marketplace members with their behavioral and physical healthcare needs.
• Supported Management staff work to help members achieve optimal clinical, financial and quality of life outcomes, including safely and effectively transitioning Dual and Star Plus and marketplace members from acute or inpatient care to lower levels of care and/or home in a cost-efficient manner.
• Functioned as a hands-on supervisor, providing direction and guidance to the care management team, utilization management team, and disease management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements.
• Managed staff caseloads and assigns cases appropriately with regard to complexity of medical or psychosocial needs and case manager experience (L MSW, other allied fields).
• Oversee the staff use of the electronic case management and utilization management [support coordination] documentation system in compliance with standard ICA processes, standard documentation styles, and HIPAA. Arranged training as needed.
• Managed, coached and evaluated the performance of team members; provided employee development and recognition; and assists with selection, orientation and mentoring of new staff.
• Promoted multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina duals and star plus members.
• Worked with the Director to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Audited case management [supports coordination] assessments and care [individual plan of service] development for completeness and timeliness according to state requirements as well as utilization management productivity numbers and process implementation.
• Monitored onsite hospital discharge visits and post-discharge visits to assure continuity of care and prevent unnecessary readmissions.
• Monitored the completeness of the Transition of Care (ToC) assessment and the timeframes for contact are per ToC protocols.
• Utilized Model Of Care for CMS and educated, trained, many employees on all aspects of CMS requirements and was a leader through the CMS audit Process
• Utilized NCQA standards for Medicaid, and Medicare members and educated, trained, many employees on all aspects of NCQA requirements and was a leader through the NCQA audit Process
RN MANAGER/INTERIM DIRECTOR OF UTILIZATION AND CARE MANAGEMENT
Molina Healthcare Irving, TX
June 2014 - November 2017
Hired to manage a team of Clinical Review Processors, Clinical Review Clinicians Case Managers and Licensed Practical Nurses tasked with the clinical review of Medicare, Medicaid and commercial payor prior authorizations. Management of RN Case Managers Run the day to day duties for my RN's payroll, budgeting, education, and building processes for Molina to adopt.
• Guided, coached and directed 20 clinical team members responsible for 600 daily authorization requests for nursing, enteral feedings, home health and Durable Medical Equipment (DME) services. Managed 39 RN Case managers that go out to Nursing Facilities to conduct assessments and submit items to utilization management
• Prioritized and reduced the average case load of 3,000 pending prior authorizations by 70% within the first six months. Reduced the amount of outstanding Face to face assessments that were needed complete from the state 3000 to now 800 by using new streamline processes to become more efficient
• Prioritized and reduced the average case load of 4500 face to face assessments for the Dallas El Paso area down to being caught up and able to set a case load of 150 members to each CM ratio
• Earned recognition from management as an innovator within the department as a result of process improvements, leadership and reduction of pending case load
• Worked with members, providers, federal and state agencies, and multidisciplinary teams to assess, plan and coordinated an integrated delivery of health care across the continuum of care. As Molina expands its operations into new states and additional markets, it aims to take concrete steps to comply with the ever-dynamic market regulations. The CMS and States Liaisons Unit at Molina works in sync with Compliance team to oversee the implementation of new regulations, ensure overall regulatory compliance, and maintain accountability for relationships with key CMS and regulatory agency stakeholders.
• Oversaw a Care Management team responsible for supports coordination, community resources, health management, and/or transition of care activities to assist Dual, Star plus and marketplace members with their behavioral and physical healthcare needs.
• Supported Management staff work to help members achieve optimal clinical, financial and quality of life outcomes, including safely and effectively transitioning Dual and Star Plus and marketplace members from acute or inpatient care to lower levels of care and/or home in a cost efficient manner.
• Functioned as a hands-on supervisor, providing direction and guidance to the care management team to ensure implementation of activities that align with the model of care and that meet regulatory requirements.
• Managed staff caseloads and assigns cases appropriately with regard to complexity of medical or psychosocial needs and case manager experience (L MSW, other allied fields).
• Oversaw the staff use of the electronic case management [support coordination] documentation system in compliance with standard Molina ICA processes, standard documentation styles, and HIPAA. Arranged training as needed.
• Managed, coached and evaluated the performance of team members; provided employee development and recognition; and assists with selection, orientation and mentoring of new staff.
• Promoted multidisciplinary collaboration, provider outreach, and engagement of family and caregivers to enhance the continuity of care for Molina duals and star plus members.
• Worked with the Director to ensure adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and performance indicators.
• Audited case management [supports coordination] assessments and care [individual plan of service] development for completeness and timeliness according to state requirements.
• Monitored onsite hospital discharge visits and post-discharge visits to assure continuity of care and prevent unnecessary readmissions.
• Monitored the completeness of the Transition of Care (ToC) assessment and the timeframes for contact are per ToC protocols.
• Utilized Model Of Care for CMS and educated, trained, many employees on all aspects of CMS requirements and was a leader through the CMS audit Process
• Utilized NCQA standards for Star Plus state members and educated, trained, many employees on all aspects of NCQA requirements and was a leader through the NCQA audit Process.
• Had a Team of CM that worked a small contract for Workman's Comp and would follow the employees and make sure they received proper care and utilization and educated employees on the care and helping them understand their benefits.
EDUCATION
Family Nurse Practitioner
Purdue University Global, Indianapolis, IN
May 2021
Masters of Business Administration
Keller University of Business, Addison, IL
August 2020
Masters in Nursing
Chamberlain University College of Nursing, Columbus, OH
December 2014
Bachelors of Nursing
Chamberlain University College of Nursing, Columbus, OH
December 2014
Associates in nursing
Marion Technical College, Marion, OH
June 2009
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