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Data Entry Medical Review

Location:
Hammond, LA
Posted:
December 03, 2022

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Resume:

Jeannette H. Higgins, RN, CPHQ

Post Office Box **31

Hammond, LA 70404

985-***-**** (Home)

985-***-**** (Cell)

adtt77@r.postjobfree.com

Accomplishments: Proven ability to direct dramatic improvements in quality.

•For example, as a new Director of QA/RM, after inheriting 80 Type-One recommendations from a previous JCAHO survey, worked closely with Medical Staff, Administration, and Department Mangers, and others to define and implement improvements, which, in the next JCAHO survey, resulted in zero Type-One recommendations and five commendations.

•Identified, conducted analysis of data, team meetings, etc to resolve a Risk Management issue of Betadine Burns in the Intra-operative division of surgery at a major hospital.

•Appealed denials of payment successfully on at least 4 occasions in my career, which resulted in 50-75% recovery of re-reimbursement.

Summary:: I have over 20 years of experience in Performance Improvement, Risk Management, Utilization Review, Infection Control, Compliance, Legal and Patient Advocacy and implementation of local, state and federal guidelines as well as regulatory standards implementation. to include Joint Commission, DNV, DHH, CMS Conditions of Participation, OSHA, etc.

Professional Experience:

5/22/17- 5/24/18 St Theresa Specialty LTAC Hospital-- hospital is closing -in process of buy-out

3601 Loyola Ave

Kenner, LA 70065

Director, Quality Improvement / Risk Management

Supervise: Infection Control, Employee Health, Medical Records Data Collection, Data Entry Clerks, Social Services, Case Management

•Direct all components of the PI/RM/IC/EH/ Compliance/Medical Records functions for a new Surgical Hospital according to a newly developed PI Plan.

•Medical Staff Peer Review, and direct core measures data collection for a surgical hospital.

•Prepare relevant reports, agendas, summaries, and packets for Medical Staff Committees, Administration, and Board of Trustees, as well as Hospital Committees.

•Educate unseasoned Directors on the PI/RM processes and assist them with the development of the PI processes and indicators in their departments.

•Facilitate Hospital–wide performance improvement activities including performance improvement teams.

•Direct with the survey preparation readiness for both the Accrediting Agencies as well as the federal and state surveys.

•Conducted extensive review processes according to the PI/RM plan to meet the federal, state, and local standards.

•Design, develop, and implement processes to meet the standards of all regulatory and accrediting agencies.

•Prepare for and conduct QI/RM meetings, and conduct/coordinate all follow-up activities as required.

•Conduct Medical Staff reviews/ Core Measures reviews/data entry.

•Prepare for all Medical Staff Committees and hospital committees as needed. Develop, coordinate, and facilitate PI teams as needed.

•Educate nursing staff on PI statistics and how to aggregate data. Conduct and perform data analysis monthly on the appropriate Medical Staff Reviews. Peer Review

•Educate staff on the PI process-ongoing. Function as a resource for quality and regulatory issues and concerns.

2012 to present Quality Improvement Consultant with the emphasis in the Components: Regulatory Standards Implementation, Joint Commission Survey /

DHH Preparation/Implementation

Quality/Performance Improvement

Safety/ Risk Management

Employee Health/ Infection Control

10/20/14 –10/16 Louisiana Healthcare Connections -Centene

2525 Archives Blvd, Suite 310

Baton Rouge LA 70809

Quality Improvement- Appeals Department

Clinical Appeals Coordinator

Review clinical information for appeals for medical necessity denials and obtain supporting clinical information from the providers, Prepare cases for review. Submit to the correct medical reviewer of like specialty for medical necessity review.

Call providers and members to update them on results of the medical review and Prepare and send letters of resolution to both the provider and the member. Ensure that the letters are compliant with State and NCQA regulations.

Enter clinical information and supporting data on DHH log report for each appeal. Maintain current knowledge of NCQA and state/federal regulations. Attend and participate in numerous meetings.

11/1/2010-8/6/2012 30 bed Cypress Pointe Surgical Hospital (Start-up)

42570 South Airport Road

Hammond, LA 70403

Director, Quality Resources

Performance Improvement, Risk Management, Infection Control, Employee Health, Utilization Review

Supervise SCIP Coordinator,

Case Management Coordinator-4 months

•Direct all components of the PI/RM/IC/EH/ Compliance/Medical Records functions for a new Surgical Hospital according to a newly developed PI Plan.

•Medical Staff Peer Review, and direct core measures data collection for a surgical hospital.

•Prepare relevant reports, agendas, summaries, and packets for Medical Staff Committees, Administration, and Board of Trustees, as well as Hospital Committees.

•Educate unseasoned Directors on the PI/RM processes and assist them with the development of the PI processes and indicators in their departments.

•Facilitate Hospital–wide performance improvement activities including performance improvement teams.

•Direct with the survey preparation readiness for both the Accrediting Agencies as well as the federal and state surveys..

•Conducted extensive review processes according to the PI/RM plan to meet the federal, state, and local standards.

•Facilitate preparation for the past start up survey by DNV accrediting body as well as the upcoming Annual NIAHO Survey.

•Design, develop, and implement processes to meet the standards of all regulatory and accrediting agencies.

•Prepare for and conduct QI/RM meetings, and conduct/coordinate all follow-up activities as required.

•Conduct Medical Staff reviews/ Core Measures reviews/data entry.

•Prepare for all Medical Staff Committees and hospital committees as needed. Develop, coordinate, and facilitate PI teams as needed.

•Educate nursing staff on PI statistics and how to aggregate data. Conduct and perform data analysis monthly on the appropriate Medical Staff Reviews. Peer Review

•Educate staff on the PI process-ongoing. Function as a resource for quality and regulatory issues and concerns.

4/19/2010 -10/22/2010 Meadowbrook Specialty Hospital—Hospital closed

204 Energy Drive

Lafayette, LA 70508

337-***-****

Director, Quality Resources

Performance Improvement /Risk Management/ Infection Control/ Employee Health/ Compliance/ Medical Records/Education

•Direct all components of the PI/RM/IC/EH/ Compliance/Medical Records functions for a medium size LTAC hospital according to a developed PI Plan.

•Conducted extensive review processes according to the PI/RM plan to meet all federal, state, and local standards.

•Facilitate preparation for the up-coming Joint Commission survey.

•Design and implement processes to meet the standards of all regulatory and accrediting agencies.

•Prepare for and conduct QI/RM meetings, and conduct/coordinate all follow-up activities as required.

•Conduct Medical Staff reviews/ Core Measures reviews/data entry.

•Prepare for all Medical Staff Committees and hospital committees as needed. Develop, coordinate, and facilitate PI teams as needed.

•Educate nursing staff on PI statistics and how to aggregate data. Perform data analysis monthly, quarterly and annually.

•Conduct annual evaluations of the performance improvement functions.

7/7/06- 2/28/2010 Audubon Home Health

3050 Teddy Drive

Baton Rouge, La 70809

Manager, Quality Improvement/Risk Mgmt/Infection/Control/Compliance

•Facilitate and coordinate all PI/RM/IC activities for a medium size home health organization according to a developed PI/RM Compliance plan.

•Conducted extensive review processes according to the PI/RM plan to meet all federal, state, and local standards.

•Design and implement processes to meet the standards of all regulatory and accrediting agencies.

•Prepare for and conduct QI/RM meetings, and conduct/coordinate all follow-up activities as required.

•Perform analysis of data and report findings, and facilitate follow-up activities.

•Prepared 45 initial inherited ADR’s for CMS-FMR, which was decreased from 40% to 7% denial of payment rate in about 3-4 months after arrival at Audubon. This resulted in the region being removed from the CMS Focused Medical Review on which they had been placed prior to my arrival.

•Design the Emergency Plan according to the required state Emergency Plan and ensure the updates and education are current.

•Serve as the Emergency Disaster Coordinator for the agency to implement the Disaster Plan as needed especially during Hurricane season.

•Monitor the weather conditions and advise the administrative team as needed. Conduct the in-services for the Emergency Plan yearly and as needed.

•Develop and conduct an intensive In-service for the Staff and conduct one-on-one in-services on the ABN’S (Advance Beneficiary Notices).

3/8/03-3/18/06 Odyssey Healthcare—Business closed

7905 Wrenwood Ave

Baton Rouge, La 70809

Business has closed

Manager, Quality Improvement/Risk Mgmt/Infection/Control/Compliance

•Facilitate and coordinate all PI/RM/IC activities for a regional hospice according to a pre-established PI/RM Corporate Compliance plan.

•Conducted extensive review processes according to the PI/RM plan to meet all federal, state, and local standards.

•Design and implement processes to meet the standards of all regulatory and accrediting agencies.

•Prepare for and conduct QI/RM meetings, and conduct/coordinate all follow-up activities as required.

•Perform analysis of data and report findings, and facilitate follow-up activities.

•Prepare all reports for Corporate QI/RM quarterly meetings for the Baton Rouge region.

•Prepared 45 initial inherited ADR’s for CMS-FMR, which was decreased from 40% to 7% denial of payment rate in about 3-4 months after arrival at Odyssey. This resulted in the region being removed from the CMS Focused Medical Review on which they had been placed prior to my arrival.

•Conduct annual and on hire in-services and coordinate with other managers for all in-services for the staff.

•Conducted admission reviews and approved admissions on all patients post Hurricane Katrina.

•Developed the Emergency Plan prior to Hurricane Katrina and conducted extensive staff inservices—pre and post Hurricane Katrina.

•Conducted constructive critique of the effectiveness of the Hurricane plan. Coordinate with the leaders in order to facilitate the effectiveness of the Hurricane Disaster Plan

Served as Interim Acting Patient Care Manager during the absence of the active PCM and for a 3 month duration until the position was filled

7/23/01-10/2002 East Jefferson General Hospital

5300 Houma Blvd

Metairie, Louisiana 70006

Manager, Performance Improvement/ Risk Management for the Division of Surgical Services

•Facilitate preparation for Accreditation Survey by Joint Commission on Healthcare Organizations for a large 560 bed Acute Care Hospital,

•Refine the Existing PI/RM program--facilitating the implementation of Clockwork Surgery through the Preadmission Testing (PAT) Multi-disciplinary Team Meetings.

•Conduct and analyze data collection on First Case-On Time Starts and Turnaround Times within the Operating Room for a 20 room OR suite with a high volume surgery schedule,

•Facilitate and handle all Risk Management issues within the Department of Surgery; Coordinate with the Legal Department when necessary,

•Direct the PI/RM for the other areas within the Division of Surgery to include PACU, SDS, Endoscopy as well as Surgery,

•Serve as a resource to the Hospital JCAHO Preparation Team and serve on the Committee. Also serve on the Hospital-wide Environment of Care Committee, Prepare the bimonthly Laser Report and other Risk Management reports as needed. Serve on the Peri-operative Committee and submit monthly PI reports for the Medical staff and Anesthesia,

•Conduct Special Risk Management studies and analysis of the data in order to resolve the issues

1/22/01 –6/30/01 Lallie Kemp Medical Center

LSU Health Science Center

Healthcare Services Division

52579 Highway 51 South

Independence LA 70443-2231

RN Program Manager in Compliance Department

•Conduct all new-hire orientation and annual employee retraining,

•Conduct extensive Medicare/ Medicaid, and Laboratory Screening Audits utilizing Tri-Span and local Medical review policies in preparation for reports to the government, and Medi-code 2001 CPT Expert code book and the Guide to Code linkage for Laboratory Services St Anthony’s publication,

•Develop and conduct an intensive Inservice for the Nursing Outpatient Staff and conduct one-on-one in-services on the ABN’S (Advance Beneficiary Notices),

•Assist, and prepare Physician Educational Inservice on Compliance, and prepare report on Physician Education,

•Compile LMRP for the Outpatient Clinics and Ambulatory Outpatient Surgery in conjunction with the Medical Justification Ready-Reference Manual of Acceptable Diagnosis Codes and descriptions as identified by Tri-Span Health Services.

1980 Self-employed—Owner/Manager of our own businesses

Consultant/and Contract Staff RN intermittently

Clinical Experience:

Heritage Manor Nursing Home –Director of Nursing—One year

•Successful state survey with no citations/recommendations

•College Health Nursing—Loyola and Emory University -- Three years

•Ochsner Clinic –Staff Float Nurse in the clinic for three years

•Charity Hospital Staff Nurse in Delivery suite --Two years plus

Licensure: RN licensure maintained in Louisiana and Georgia

Education: Graduate: Charity Hospital School of Nursing—New Orleans, LA

(Three Year Registered Nurse Diploma)

Attended: Tulane University—New Orleans, LA

(Studied Liberal Arts)

College of St. Francis—Joliet, IL

Studied Bachelor of Science, Health Arts)

CPHQ Certification: NAHQ Certification:

CPHQ Certification through the National Association of Healthcare Quality, 1983 –present

Professional Affiliations:

National Association of Healthcare Quality (NAHQ)

•Nominated for Member Services Director--1997

•Served as Speaker 1997

Louisiana Association of Healthcare Quality (LAHQ)

•Served as Speaker—1997

•Nominating Committee Chairperson –1997

•Elected Region Representative—1998-1999, 2006-2009

•Educational Chairperson for the Annual Educational seminar in New Orleans at the Ponchartrain Hotel

New Orleans Association of Healthcare Quality (NOAHQ)

•Served as Secretary—1997 & 1999

Baton Rouge Association for Healthcare Quality

•Elected Regional Representative 2006-current

•Served on the Education Committee--2007

•President, Baton Rouge Assoc HQ---2009-2010

American Association of Employee Health



Contact this candidate