Utilization Review Case Management

GAIL FONTANA, MSN, RN, CCM

CAREER SUMMARY

Successful and progressive record of experience in diversified areas of healthcare, including Case Management, Utilization Review, Denials and Appeals, Discharge Planning, Clinical Documentation Improvement, Revenue Cycle, Care Coordination, Workman’s Compensation, Hospice. Excellent leadership, management team building and communication skills, with proven ability to set and achieve In-depth and extensive experience in managing union and non-union Case Management, Utilization Review, Discharge Planning and Social Services departments within for-profit and not -for-profit systems. In –depth knowledge of all federal and state regulatory requirements for Utilization Review including DNV, JCAHO, CMS, QIO and RAC Audits, HEDIS. Excellent Change Agent with proven results.

EDUCATION

2012

MSN

American Sentinel University, Boulder, Colorado

2009

BSN

Grand Canyon University, Phoenix Arizona

1993

ADN

Richard J. Daley, Chicago, Illinois

University Of Illinois Hospital

Chicago, Illinois 02/2022 - Present

Case Management Consultant – Senior Case Management Leadership

Oversight of 500 bed level one trauma state hospital

•100+ employees

•Union Environment

•Restructure of Case Management Workflow

•Physician Advisor Education

•Lower observation LOS by 30 hours

•Revamping of interdisciplinary meeting

•Assistant Director of UR and DC planning education

•Staff education for throughput, surgical level of care

•CMS guidelines for Case Management reinforced

•Observation percentage reduction

LifePoint Maria Parham

Henderson, NC 11/2021-02/2022

Interim Director of Case Management

•Oversight of Utilization Review, Discharge Planning, PAC program

•Staff education for UR and DC planning best practices

•Decreased LOS by.5 days, DC planning reviews from 60% to 90%

•UR restructure and education provided on level of care, payor strategies

•Triad Model of Case Management reinforcement

•Restructure of workflow processes resulting in decreased LOS

•IMM compliance, patient choice, BPCI workflow improvement

•CMS Compliance incorporated into daily CM/DC planning/PAC workflow

•Job Descriptions and Policy updates

•Worked closely with CFO and regional CM VP resulting in improvement of metrics

Franciscan Alliance

Hammond, IN 03/2021-10/2021

Interim Divisional Director of Case Management Hammond/Dyer/Munster/Olympia Fields Campus

•Oversight of Hospitals for Utilization Review, Discharge Planning

•Observation Initiative lowering obs Oversight of Utilization Review, Discharge Planning, PAC program

•Staff education for UR and DC planning best practices

•Decreased LOS by.5 days, DC planning reviews from 60% to 90%

•UR restructure and education provided on level of care, payor strategies

•Triad Model of Case Management reinforcement

•Restructure of workflow processes resulting in decreased LOS

•IMM compliance, patient choice, BPCI workflow improvement

•CMS Compliance incorporated into daily CM/DC planning/PAC workflow

•Job Descriptions and Policy updates

•Worked closely with CFO and regional CM VP resulting in improvement of metrics

•ervation rate by 11% in one month

•Education to Managers and staff for throughput, CMS regulation

•Consolidation of policies, UM plan overview

•UM committee restructure

•Hospital Reduction in Force participant

•Restructure of workflow process, staff education, regulatory compliance

Interim Case Management Nurse Navigator-

Takoma Park, WA

Covid 19 Disaster Team

•Navigation of Covid 19 Patients from Emergency Room

•Discharge planning for Covid 19 Patients

•Identify, assess, plan, implement, coordinate for Covid 19 field hospital

•Educate hospitalists on throughput, Length of Stay

•Improve patient satisfaction for discharge planning

•Ensure care plan goals are met

Deaconess Health System

Evansville, IN 5/2020-10/2020

Interim Director of Case Management-Covid 19 Focus

•Restructure of Case Management Department for 2 campuses

•Reengagement of Team

•Employee Retention resulting in low turnover of staff

•Education for UR, DC planning, Social Services- Triad Model

•LOS for OBS reduction education

•Physician Advisor Education and Training

•Education for Lead Case Managers

Prime Health-Southern Regional Medical Center

Riverdale, GA 3/2020-5/2020

Interim Director of Case Management-Covid 19 Focus

•Team building

•Case Management Education of regulation

•Embedded regulatory compliance in case management operations

•Denials Reduction by 20%

•Revamping of UR process

•Throughput of Covid 19 patients

Bethesda Hospital East and West

Boynton Beach, FL 1/2018-3/2020

Divisional Director of Care Coordination/Denials Dept/CDI for Bethesda Health

Two facilities, 1 was 401-beds and the other 90-bed with a total of 116 employees

•Implementation of final stages of Care Logistics Program

•Engage Care Coordination Team by Education, process improvement, mentoring

•Provide education for UR/DC planning/throughput with LOS reduction from 5.0 to 4.1 days

•Reduction of observation by 10% in 30 days, from 29% to 20%

•Physician education for Total Knee Medicare Changes, Documentation improvement

•Designed physician advisor program and consulted for System Wide Program

•CMI from 1.6 to 1.73 by 3M 360 implementation and CDI staff development

•Monthly CDI dollars 400-600K

•Assisted with development of Palliative Care Program10/2017-12/2017 McBee and Associates/Adventist Health System Independent Case Management Consultant LaGrange, IL

•Re-engagement of UM Case Management team for three hospital System

•Education enhancement for Utilization Review Department

•Denials and appeals department workflow redesign

•InterQual/Milliman reinforcement

Tahoe Forest Health System,

Incline Village NV and Truckee, CA 7/201*-**-****

Interim System Director of Case Management

2, 25-Bed Critical Access Hospitals

•New EPIC system implementation for Case Management, Care Coordination and Transition of Care Depts.

•Implemented Case Management in the ER, immediate results improving care transitions, level of care, revenue enhancement for surgical cases

•Retraining for Case Management Manager resulting in departmental work flow improvements

•InterQual training/IRR implementation improving level of care and length of stay

•Outpatient Care Coordination restructure

•Union environment with union negotiations

Vail Valley Medical Center

Vail, CO 5/2017- 7/2017

Director of Case Management

25-bed Critical Access Hospital

•International Surgical Institution- Level of care correction resulting in correct level of care, improving revenue

•Operational Plan redesign created and executed for case management resulting in departmental improvements

•Improved regulatory compliance for Joint Commission and CMS by education/policy and procedure/in-services

WellStar Health System

Atlanta, GA 4/2017-5/2017

Director of Case Management

325-bed Non-for-Profit Facility

•Oversee Care Coordination team while Director out on short leave

•Restructure length of stay meetings resulting in lowering of length of stay, readmissions

•Surgical level of care hardwired to capture inpatient only cases increasing revenue

Alameda Health System

Oakland, CA 12/2016-4/2017

Interim System Director of Care Management

250-bed, 60-bed and 35-bed Public Hospitals, 15-bed Rehab Hospital, 100-bed SNF

•Oversee Care Management for 4 Public Hospitals, Major trauma center-Union Environment

•SNF Facility and Acute Rehab Facility oversight resulting in improvement of length of stay, revenue enhancement

•Reinforce CMS standards- IMM letter, avoidable days, Medicare reviews, admission order accuracy

•Revenue Cycle restructure lowering backlog by 25 million, exceeding budget by 1.5 million

•Allscripts, Midas and Executive Health Resource implementation for Case Management

•Physician education for LOS, level of care, CDI resulting in lowering length of stay, increasing CMI, reducing

•admissions for social cases

St Joseph

Phoenix, AZ 09/2016-12/2016

Regional Interim Director of Case Management

600-bed Non-For Profit Facility and 25-bed CAH

•Oversight of 98 staff members, 3 managers

•Corporate initiative implementation of case management redesign

•Length of Stay reduction by 0.5 days

•Decrease Observation conversion rate by 25%

•Reinforce CMS standards of observation notice, IMM letters resulting in 100% compliance

White River Medical Center

Batesville, AR 7/2016-10/2016

Interim Director of Case Management

210-bed Non-For-Profit, Trauma Center

•Combine UR/DC planning to Dyad Model of Case Management, Train new CM Director

•Create ED case management program, train new CM in the ED

•Educate physicians on appropriate level of care, reducing obs conversions by 30%

Highlands Regional Medical Center

Prestonsburg, KY 4/2016-7-2016

Interim Director of Case Management

100-bed Community Hospital

•Reduction in observations by 40%

•Streamline UR review process by staff education, IRR, teaching UR concepts

•Reduction in length of stay measures

•Train new permanent Director of Case Management using CM best practices

Healthnet Government Services

Woodland Hills, CA 6/2015-4/2016

Veterans Choice Program- Point of Contact RN (Medical Staffing Network)

Inpatient and Outpatient Case Management Services for US Military and Department of Defense

Love Lace Medical

Albuquerque NM 7/2014-5/2015

Interim Divisional Director of Case Management

250-bed For-Profit, acute care facility/ 55-bed Heart Hospital

•Assist with restructure of case management department at multiple hospitals and for the division

•Oversee staff of 30 FTE’s

•Implement new Emergency Room Case Management team resulting in effective transitions from the ED

•Lowered observation rate by 30% in 6 months

•Length of stay reduction measures by .5 days

•Physician advisor hired, trained and strategically implemented

•MCG electronic case management system implemented

•Denial recoupment of 2 million dollars in 6 months

Iasis/SW General Hospital

San Antonio, Texas 10/2013-6/2014

Interim Director of Case Management

327-bed For-Profit, Community Hospital

Reduction of one day inpatient stays by 25%

•Reduce observations by 25 hours, eliminating need for CDU unit

•Recoup 1 million dollars in denial revenue in 8 months

•Successful audits with RAC, reducing payback by 4 million dollars

Rideout Memorial

Yuba City, CA 1/2010-6/2013

Interim System Director of Case Management

Interim Director of Case Management/Clinical Data Improvement/Chaplaincy Program for 170 and 55-bed Non-For-Profit, Community Hospital

•Restructure of Medi-caid TAR by implementing electronic payment procedure-increasing revenue by 75%

•Develop Physician Advisor Program (EHR)

•Decreased Length of Stay from 5.6 to 4.0.

•Decreased Re-admission Rate from 21.6 to 13.3.

•Increased Clinical Documentation Revenue to $1.9 million in 11 months.

•Increased bottom line revenue enough to move revenue from negative to positive within 3 months.

•Reduced RAC audit risk by restructure of Utilization Review Process

•Decreased Hospital Transportation cost by 1 million dollars annually

2000-2010 Various Agencies

Director of Case Management, Workmans Compensation high Dollar Consultant

CERTIFICATIONS

BLS

CCM

expires 10/2022

expires 11/2025

PROFESSIONAL AFFILIATIONS, HONORS, PUBLICATIONS

Member of CMSA, ACMA

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