Case Manager Management Specialist

Bo Iglehart, RN, BSN, CCM

www.linkedin.com/in/flnursebo 954-***-**** *************@*****.*** Lakeshore, FL 33854

SUMMARY

Compassionate and organized Certified Nurse Case Manager accustomed to treating diverse patient needs while managing dynamic conditions. Dedicated to maintaining efficient, high quality and performance driven care units. Offering excellent clinical knowledge and judgement combined with critical thinking, problem solving and strong documentation. Experienced in managing emergent cases with grace and efficiency. Well versed in evaluating staff performance, conducting staff development, and implementing policy and procedures that reflect the ever-changing regulatory standards and guidelines set by accrediting agencies. Strong communicator and tactical planner with top skills in engagement, delegation, and empowerment. Thoroughly prepared, experienced. Positive, enthusiastic CCM focused on patient advocacy and truly making a difference in elevating healthcare through the therapeutic use of self and ethical stewardship of resources.

SKILLS

Triaging patient concerns Intake and Discharge Performing patient intakes

Relationship development Patient relations Patient Care and Safety

Organization Unit administration Operational improvement

Process improvement Problem resolution Records Management

Team building Team management Quality assurance control

Computerized Charting HIPPA/confidentiality Staff Development and Precepting

Infection control procedures Quick problem solver Calm and level -headed under duress

EXPERIENCE

Holy Cross Hospital-Trinity Health/Cynet Health April 2022- May 2022

Travel RN Case Manager

Collaborate and coordinate with the interdisciplinary team (including Physicians, Residents, Hospitalists, Nurses, Physical Therapists, Pharmacist, Respiratory Therapists, Occupational Therapists, Speech Therapists, Registration and Administration) to establish clinical appropriateness for inpatient or Observation status and safe/patient-centric discharge plan, regardless of payor source, with a high degree of autonomy for 20-35 acute care patients daily.

Discuss and inform physicians of appropriate status based on documentation and coordination of insurance/resources.

Educate patient/family on disease/condition management and expected outcomes.

Implement Case Management activities for all age groups (birth to geriatric) that promote continuous improvement in the coordination of care across the continuum.

Iglehart p. 2

Monitor/manage clinical resource consumption (including denials, peer to peer review, appeals)

Ensure accurate clinical documentation in EMR (electronic medical record).

Promote and develop care plan for continuity of care and post-hospital planning to optimize cost with efficient utilization of available resources to decrease re-hospitalizations and maximize health potentials.

OPTUM Care, a UHG Company November 2020 – February 2021

RN Care Manager-Kissimmee

Effectively and efficiently provide weekly RN case management of 30-50 insured, chronic and/or complex patients, displaying various diseases and conditions to achieve and/or maintain optimal wellness. Guide and empower patients/families to engage in patient -centered and evidence -based interactions with resources appropriate for care and well-being.

Provide coordination of services for members who meet established criteria, with an emphasis on education/self-management and promoting quality care and cost-effective outcomes.

Utilization of collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor

progress, evaluate Member status, discharge Members, and fully document the individualized member care management process and outcome.

Initiate and implement the management and oversight of a caseload of moderate - high risk Members with complex medical/psychosocial needs.

Active participant in IDT (“Grand Rounds”) Including Member presentation and all documentation in adherence to Medicare and Plan guidelines.

Conduct proactive telephonic outreach to eligible Members to engage in care management program intervention participation.

Exhibit excellent customer relationship skills including telephonic and face to face contact with all stakeholders, i.e. physicians, office staffs, nurses, vendors, and co- workers.

Maintains a current knowledge base with regards to rules, regulations, policies, and procedures relating to Medical Management. Regularly reviews and monitors compliance with the Health Plan’s policies and procedures.

DeSoto Memorial Hospital/Brundage Work Group August 2020 – November 2020

Travel RN Case Manager

Assess and evaluate the condition of the patient as to whether the patient meets criteria for hospitalization at a 49-bed rural, not for profit hospital with a 60-70% COVID 19 positivity. Effectively and efficiently manage all hospital transfers maintaining communication with all stakeholders including but not limited to attending/accepting MD, accepting facility and transportation to ensure appropriate placement, transfer facilitation, and accurate documentation. Coordinate safe discharge that is patient centric addressing the identified needs, removing barriers, and improving the health of the patient.

Iglehart p. 3

Utilizing Interqual/MCG criteria along with collecting interdepartmental documentation, ensure enough information is accurate and reflective to obtain approval or denial of services.

Proficient in analyzing/reviewing clinical information for admission, concurrent, extended length of stay for inpatient hospitalization or Observation status.

Obtain and review medical records, Hospitalist and Nursing notes, labs, assessments, H&P, and interview clinical staff including treating specialist and nurses. Extracts needed information from both electronic and faxed records accurately and timely.

Daily collaboration with treatment team to effectively establish treatment/discharge plan by conferring about the status/condition of the patient.

Coordinate care by serving as the contact point, advocate and resource for the patient, their family, and their physician, building effective relationships through trust, respect, and communication.

Maintains a current knowledge base with regards to rules, regulations, policies, and procedures relating to Medical Management. Regularly reviews and monitors compliance with various Health Plan’s policies and procedures.

Step into higher levels of responsibility as needed including Lead role.

StayWell, a WellCare Company/Healthcare Support April 2020 – August 2020

LTSS Care Manager I, RN, Region 6

Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care.

Develop, assess, and adjust, as necessary, the care plan and promote desired outcome.

Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long -term goals, treatments, and provider options.

Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio -economic needs of clients.

Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs.

Provide patient and provider education.

Facilitate member access to community -based services. Monitor referrals made to community -based organizations, medical care, and other services to support the members’ overall care management plan.

Actively participate in integrated team care management rounds.

Identify related risk management quality concerns and report these scenarios to the appropriate resources.

Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems.

Iglehart p. 4

Anthem, Inc./Healthcare Support November 2019 – February 2020

Contract Appeals Nurse, GBD Grievance and Appeals-East Region

Determine medical necessity of requests by member, providers, or their representatives by performing 1st level reviews utilizing approved evidenced-based guidelines and criteria while adhering to contractual and quality standards.

Conduct research regarding State/Federal appellate guidelines and applicable regulatory process related to the appellate process.

Evaluate clinical claim denials; reviewing for appropriateness of denial or appeal based on service rendered per documentation of clinical information, Interqual/MCG criteria, and other third-party information including Payor policy.

Provide required documentation per payor request, including clinical information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria, etc. to support appeal.

Initiate and facilitate communications with Physician practices, UM MD, Utilization Review Nurses and Coding and case management to determine the “case for appeal”. Review documented clinical records and utilizing Medical Necessity criteria including Interqual and Milliman to facilitate appeals for clinical denials.

Certifies reviews meet clinical review criteria and guidelines.

Release UM determinations to claim stakeholders following established protocols.

Works in conjunction with member of the GBD Team to provide excellent healthcare benefits as per contractual benefits to every member through utilization management.

Demonstrates proficiency in utilization of electronic tools including but not limited to PEGA, MACES, Facets, SharePoint, Web Ex, Skype as well as Microsoft Office.

Saint Agnes Medical Center/AYA Healthcare September 2019 – October 2019

Travel RN Utilization Review Case Manager

Reporting to the Manager, Care Coordination & Social Services, coordinate care and service for defined patient populations across the acute care continuum. including discharge planning, utilization management, care coordination, and support for resource utilization. Worked collaboratively with an interdisciplinary team to improve patient care through the effective utilization of the facility's resources. In meeting these goals, assumed an active role in achieving desired clinical, financial, and resource utilization outcomes.

Review clinical information and records to perform utilization assessing, monitoring, and evaluating patient care for Medical Necessity utilizing internal (Trinity) criteria along with Interqual and/or Milliman Care Guidelines (MCG).

Review prospective/concurrent/retrospective requests for inpatient and outpatient services against established criteria, referring cases not meeting guidelines to Physician Advisors.

Assess for unnecessary services and recommend other appropriate options.

Iglehart p. 5

Interface with medical facility multidisciplinary personnel to assess, collaborate and coordinate with interdisciplinary team to coordinate discharge planning.

Provide utilization management services and support to patients and providers including but not limited to pre admits. Outpatient, inpatient and continued stay reviews applying Interqual and MCG medical criteria, medical policy, and benefit information in response to requests accurately and appropriately.

United Health/Optum/Healthcare Support April 2019 – August 2019

Contract Clinical Quality Analyst, Centralized Audit Team - Optum PHS & P, Strategic Capabilities

Provide quality oversight of frontline staff by conducting monthly subjective assessments and evaluations of calls and cases managed to ensure that client services levels are met or exceeded in accordance with Optum’s policies and procedures, external customers, and regulatory standards. Apply advanced knowledge, utilizing discretion, to conduct Commercial multispecialty (including Case Management, Disease Management, Population Health Management, Health Care Decision, Cancer Support, Maternity Support, Orthopedic Health Support, Short term Disability) subjective assessments to evaluate the clinical skills and customer services provided.

Compile, analyze, and report key program data to support client goals based on National standards. and procedures.

Reference all available customer specific details and requirements when evaluating calls and cases to ensure high quality customer service.

Ensure that process and procedural changes are reflected in staff documentation, staying ahead of changing information while improving quality and effectiveness of agent and consumer engagement.

Demonstrate proficient data analysis and understanding of analytical tools and population health-related applications to highlight key findings to share with managers for coaching purposes.

Maintain quality audit results with minimum escalation due to auditor error competing 100% of monthly assignment achieving audit calibration requirements and accurate application of audit tools.

LA Care Health Plan/BroadPath Healthcare Solutions May 2018 – February 2019

Contract/Case Management Specialist-Case Manager (Remote/Virtual)

Analyzed and integrated Case Management activities for Special Needs/Medi-Cal populations with chronic, high risk and/or complex conditions to address unique, individual challenges to coordinate high quality healthcare, ensuring essential services, affordable care, increasing preventative services and providing seamless transitions to facilitate desired outcomes that are in the best interest of member with a case load of 40-60.

Iglehart p. 6

Conduct assessments including triage, clinical and psychosocial to determine and coordinate care throughout the continuum of care.

Provide frequent reassessments and evaluations of care received to collaborate and facilitate needed changes in the individualized plan of care.

Coordinate ongoing care in conjunction with interdisciplinary departments/ outside agencies to support evidenced based practices, including discharge planning and movement from one continuum of care to another.

Provide patient teaching to members/families/significant others to promote delivery of safe, timely, effective, efficient, equitable, and member-centered care outcomes as needed for quality healthcare.

Evaluate, oversee, and ensure that treatment plans are appropriate and related to cost and quality goals for care, incorporating legal and ethical issues.

Humboldt County Correctional Facility/California Forensic Group March 2018 – April 2018

Travel Nurse-Corrections

Maintain safety/security standards including suicide assessment and prevention measures. Conduct health assessments, screenings and inmate sick call as dictated by unit standard operating procedures.

Use approved Nursing Protocols to treat minor injuries and illnesses which do not require a physician’s attention.

Administer detox monitoring and protocol - Prepare and administer medications as per physician order.

Refer inmates to physician’s clinics, or hospitals as appropriate.

Prepare medical records for transferring inmates, including following the policy and procedure for medication transfer.

Provide inmates access to quality healthcare provided by competent healthcare professionals in a fiscally responsible manner.

Ensure that all treatments and medications are fully documented in the patient’s health record.

Gentiva Health Services, Affiliate of Kindred at Home/AYA Healthcare January 2018 – February 2018

Contract/Travel Case Manager-Home Health

Observed and monitored patient conditions. Updated all doctor orders in patient chart accordingly.

Notified doctor of any significant changes of the patient’s condition. Provided skilled nursing care in a patient’s home as ordered by the attending physician.

Performed OASIS assessments to develop an individualized plan of care and adjusted as needs change.

Helped decrease re-hospitalizations by front loading visits for high-risk patients and provided education on preventative measures.

Promoted continuity of care with appropriate admissions, transfers, and discharges.

Iglehart p. 7

Counseled patient and family on the disease/injury processes and how to manage.

Oversaw/supervised total care of patient provided by nurse aides and LPNs.

Completed all clinical documentation in accordance with agency protocol and Medicare/Federal guidelines.

Molina Healthcare July 2014 – November 2017

CM II (Case Manager II/Sr. Case Manager)-(Remote/Telecommute)

Analyzed and integrated Case Management activities for Special Needs/Dual Eligible (Medicare/Medicaid) chronic and/or complex conditions population to address unique, individual challenges to coordinate high quality healthcare, ensuring essential services, affordable care, increasing preventative services and providing seamless transitions to facilitate desired outcomes that are in the best interest of member with a case load of 120-150.

Focus on member engagement through development of professional/therapeutic relationships through therapeutic use of self to improve understanding of conditions and plan benefits to facilitate paths to maximize health potential while maintaining fiscal stewardship of available resources with validity.

Engaged over 100 previously unable to contact members in case management activities, actualizing risk scores and HEIDIS completions, which increased revenues and STARS ratings.

SinglePoint November 2012 – May 2014

Care Manager (Telecommute)

Provided telephonic case management for culturally diverse Medicaid population at a start -up company with a case load of 55-70 providing accurate documentation via electronic medical record in accordance with applicable State guidelines, rules, and regulations.

Increased knowledge and skills of co-workers through ongoing mentoring/coaching to employ evidenced base practice guidelines/standards.

Developed policy/procedures to meet contractual obligations and State requirements and standards.

Created multiple templates to standardize documentation and improve workflow process increasing efficiency.

Devised a step-by-step procedure to meet CMS guidelines to obtain authorization for members, providers, and colleagues.

Iglehart p. 8

Attentive Care July 2011 – October 2012

RN Supervisor

Delivered home health case management from intake through discharge with a case load of 60-80 with full accountability including direct supervision and education of staff in accordance with governing and accrediting agencies.

Conduct face to face assessments to determine patient needs and eligibility for services based on medical necessity, available resources, and eligibility of benefits.

Develop, initiate, and monitor care plans with coordination from Physicians for required orders.

Educate, train, mentor, guide and evaluate clinical staff in execution of orders and care plans ensuring compliance with guidelines and standards.

Participated and led in all accrediting audits and evaluations.

EDUCATION

Jacksonville University Jacksonville, FL 2009 - 2013 Bachelor of Nursing Science (BSN)

Daytona Beach Community College Daytona Beach, FL 1984 – 1986 Associate of Nursing Science (ADN) Cum Laude

Broward Community College Davie, FL 1979 – 1981 Associate of Liberal Arts (AA) President’s List

LICENSES/CERTIFICATIONS

Florida RN 1746152 eCompact RN 1746152

Inactive: California RN 725243 New York 57394 Alaska 29989 North Carolina 229031

BLS & AED (American Heart Association) 185*********

CCCM Certification Certificate Number: 4247254

EMR/SOFTWARE

Epic Meditech Cerner Eclipsys Allscripts Horizon McKesson MACES CCA QNXT Member 360 K-Link Reliance I-CUE Qfiniti OCUE Jabber Interqual MCG Doc Halo PEGA Facets IngenioRx Citrix Next Gen Compass Virtual Health Athena Midas

Outlook Microsoft Office Power Point SharePoint Web Ex Skype Microsoft Teams

OASIS UAS-NY PASSR 3008 701B 1823 ICD-9 ICD-10 CPT

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