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