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Nurse Specialist Quality Analyst

Location:
Elyria, OH
Posted:
October 29, 2021

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Resume:

Donna M. Kistemaker

*** **** ****** • Elyria, OH 44035 • ado67j@r.postjobfree.com • 440-***-****

Healthcare Compliance / Healthcare Management

Dedicated healthcare professional experienced in management, compliance, and direct patient care 25+ years

— Key Qualifications —

Proven ability to leverage nursing background to oversee compliance, training, and healthcare administrative programs to ensure safety and efficacy of care

Direct experience overseeing programs and enhancing compliance to state and federal organizations

Highly trained nurse ready to apply dedication to patient care excellence and improving outcomes; committed to setting and meeting rigorous healthcare standards in a challenging industry climate

Adept communicator, team leader, and trainer providing coaching to colleagues and healthcare teams to ensure top performance across all departments

Educational Background

Capella University, MSN Nursing Leadership and Administration

Chamberlain College of Nursing, BSN

Fairview Hospital School of Nursing, Nursing Diploma

Cuyahoga Community College, Associate of Science

ICM School of Business, Medical Assisting Diploma

Ohio Nursing License

Professional Experience

United Healthcare - Dublin, Ohio

Manager Clinical Quality – MyCare Ohio Incident Management, 4/2016 to Present

Hand-picked to serve as the manager of the MyCare Ohio Incident Management Department. Ensure all processes and procedures adhere to Medicare and Medicaid regulations and guidelines. Interface with senior leadership and department managers to gather data, analyze and prepare reports, audit preparations and tracking and trending. Plan, coordinate, and schedule project tasks, working across all business units to define project scope, establish metrics, conduct audits and monitor project status. Development and revision of departmental policies and procedures. Develop and present trainings.

Credited for proactively researching issues in a timely manner

Participate in weekly meetings with the Ohio Department of Medicaid developing pathways to improvement for the members in the community

Identify quality of care and quality of service concerns

Successfully led three Incident Management Audits with the Ohio Department of Medicaid with a perfect score

100% on Vital Signs Score (Employee Satisfaction)

Care Manager/ Waiver Liaison, 4/2014 to 4/2016

Managed a caseload of waiver/non-waiver members. Care coordination and Case management provided to MyCare Ohio members.

Served as a vital waiver liaison and consultant between United Healthcare and Areas on Aging to troubleshoot and resolve issues related to providers, members, benefits and programs

Coordinated benefits through various payment sources

Recognized as a self-directed, autonomous team member committed to overall company success while delivering top performance as an independent contributor

Cleveland Clinic – Independence, Ohio

Case Manager/Remote Care Coordinator, 10/2013 to 4/2014

Assisted with the development of Clinical Quality Metrics for the Quality Alliance. Assisted members in locating a PCP. Collected and analyzed data to develop ways to improve efficiency of care. Proficient with EPIC EMR. Monitored claims for high utilization on members with chronic medical conditions and referred them to the appropriate resources to aid them and their families in monitoring their chronic medical conditions.

Educated providers and staff on HEDIS and how to manage data collection

Educated on Patient Centered Medical Homes, discharge planning, and health and wellness interventions

Medical Mutual of Ohio – Cleveland, Ohio

Clinical Quality Analyst, 8/2012 to 10/2013

Review and Investigation of Quality of Care and Quality of Service issues. Developed Corrective Action Plans. Strategic development and oversight of quality initiatives supporting HEDIS measures, NCQA standards, CMS regulations and Affordable Care Act Legislation.

Managed a diverse variety of clinical quality improvement initiatives and developed educational materials for members and providers (Asthma, COPD, Low Back Pain, Smoking Cessation, etc.)

Analyzed data for tracking and trending to identify opportunities for improvement and develop initiatives to close care gaps

Responsible for completing assigned projects within strict timeframes

Medical Underwriting Analyst, 5/2007 to 8/2012

Served as team lead to supervise, train, and mentor colleagues and new employees. Served as the main link between Medical Mutual and the broker in making sound determination of insurance coverage. Communicated daily with brokers and members. Effectively negotiated with the sales force. Experience with network discounts.

In depth knowledge of underwriting principals and judgement in the review of renewal rate reduction and the line of business changes

Manual underwriting and collaboration with clients

Senior Utilization Review Nurse Specialist, 12/1997 to 5/2007

Managed initial, concurrent and retrospective review of cases. Applied knowledge of disease continuums and expected patient outcomes. Utilized clinical expertise and standards of practice.

HCPCS, CPT, ICD Coding

Appeals and Grievances

Written and verbal communication with physicians, members, internal departments and brokers to facilitate the Medical Review processes

Additional experience gained as a Nurse at Rehabilitation facilities, hospitals, and physician’s offices

Professional Development

Additional Training: IHI Basic Certificate in Quality & Safety, Net Promotor Score Training, Focused Leadership

Technologies: MS Office (Word, PowerPoint, Excel, Access), FACETS, Epic, WebEx, Teams, Orbit, IPRO



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