Case Manager Utilization Management
Resume:
Home Phone 916-***-****
Mobile 916-***-****
Sacramento, CA 95822
Loretta Franklin
Objective
To obtain a permanent managerial position with an organization that offers challenging and rewarding opportunities to further growth.
Skills and Abilities
Organizational/Management
Detailed oriented
Excellent time management skills
Excellent interpersonal and soft people skills
Able to teach and motivate staff in a variety of settings
Able to recognize, respond to and communicate the “big picture” to others
Good facilitator
Completes tasks promptly and efficiently
Excellent writing skills
Able to conceptualize and develop programs and systems
Customer Relations
Outgoing
Good communication skills
Assimilates and applies information to respond to customer needs promptly
Profession Skills & Certifications
Registered nurse for over 30 years, with varying levels of clinical and management experience.
Over 27 years of managed care experience
Over 27 years of UM and Case Management
Over 20 years specializing in UM and Case Management
Graduate certificate in Human Resources
Certified Case Manager (CCM)
Proficient in utilizing InterQual Criteria, Milliman, Medicare and Medi-Cal, Title 22 and other regulations.
Proficient in Epic, Cerner, Midas, Kronos, Excel, Access, Word, Power point and various other computer programs, including budgeting and productivity software.
Experience
1/1/2017 to Present Sutter Health Medical Management
Clinical Manager
Oversight and management of the Utilization Management and Compliance program for Sutter Valley Area including Sutter Medical Foundation, Sutter Independent Physicians, Sutter Medical Group and Sutter Gould Medical Group. I manage the daily operations of the managed care program. I work with the health plans and hospitals to insure appropriate utilization. I am responsible for the regulatory policies and procedures for the Medical Management department. I am a member of the Sutter Gould UM committee, the Sutter Medical Network Operations committee, the ICE Service Determination committee and other ad hoc committees aimed at improving clinical operations and industry standards for utilization and regulatory compliance. I supervise the clinical and compliance staff of approximately 12 that report directly to me and 15 indirect reports when I cover for the other manager.
7/2013 to 12/31/16 Sutter Health Medical Management
Clinical Supervisor
Oversight of the Utilization Management Program for Sutter Health, Sac-Sierra Region (SHSSR). Supervised the clinical RN staff for Sutter Select and SHSSR Utilization Management functions. I also managed the compliance aspects of our department as it relates to oversight audits, policies and procedures, legislative updates. I also am a liaison to contracting department.
5/2008 to July 2013 California Health Care Services
Chief Nurse Executive California State Prison, Sacramento, CA
5/2011 to 12/2013
Director of Nursing Folsom State Prison (FSP), Represa, CA 5/2010 to 5/2011
Supervising Registered Nurse II (SRNII) FSP, Represa, CA 5/2008 to 5/2011
I held a variety of positions from SRN II to Director of Nursing and finally to becoming the Chief Nurse Executive (CNE). As a SRNII I Supervised the TTA, R&R and Specialty Services. I worked with the FSP Access to Care team on the Asthma Initiative. I helped to redesign the chronic care delivery system to a patient-centered medical home, primary the Care Management Program to include all components of the chronic care model with a primary care focus. As the Director of Nursing, I oversaw clinical operations at FSP. As the Chief Nurse Executive, I oversaw clinical operations at both FSP and California State Prison, Sacramento. I also acted and the clinical liaison for prison operations for administrative issues. I was part of the Warden’s Operations Oversight team. As CNE I participated in statewide initiative to improve prison healthcare and develop quality initiatives. There was a managed care aspect, in addition to creating and implementing the primary care model of Medical Homes.
Experience
1/2007-2/2014 Northbay Health Systems Vacaville, CA
Case Manager- ED Case Manager- Per Diem Case Manager
Initially worked as a per diem case manager primarily on the weekends for 6 months before accepting a fulltime position in the Emergency Department-managing patient across the continuum of care.
Triaged patients’ needs in the ED and assisted with appropriate placement. Worked closely with the physicians and other clinicians to coordinate care. Assisted with bed control, patient placement, utilization review.
Using InterQual criteria-performed discharge planning, case management and insurance verification and certifications.
Developed patient centered care plans and educated patients on disease management. Secured durable medical equipment and made referrals for home health care, community resources, etc.
Experience
9/2005-6/2007 CHW-Mercy Hospital Sacramento, CA
Nurse Manager- Continuing Care Center
24 hour responsibility and management of a 38-bed unit with a staff of 50+ employees that included clinical and non-clinical staff. In two different bargaining units, SEIU and CNA.
Perform utilization management and discharge planning for patients of different socioeconomic backgrounds
Acquisition and development of clinical and non-clinical staff.
Daily oversight of the unit budget and productivity
Performance management
Continuous quality management and infection control.
Patient care management and service recovery.
Experience
4/2004-9/2005 UCD Medical Center Sacramento, CA
Discharge Planner/Case Manager
Coordinate patient care needs through the continuum of care
Perform utilization management and discharge planning for patients of different socioeconomic backgrounds
Monitored and reported quality management issues
Liaison with members of the multiple disciplinary team to formulate efficient and cost effective care plans for patients.
Experience
1998–2004 Blue Shield of California El Dorado Hills, CA
Administrative Compliance Supervisor
Developed and managed an Administrative Compliance Unit for PPO Medical Management comprised of the following programs:
Clinical Quality Management
Facility Claims Review Program
Provider Compliance program
Liaison for Provider Relations and the Law Department.
Chair of Administrative Compliance Committee, Co-chair of the Quality Management Committee and a member of the Peer Review Committee.
Realized an annual cost savings exceeding 12 million dollars.
Developed policies and procedures for medical record and claim auditing to realize above savings.
Supervised a staff of 25 nurses and non-exempt personnel from three different programs: Provider Compliance Review, Facility Claims Review and Quality Management.
Budgeting.
Recruitment/Hiring/ Staff Development and Terminations.
Participated in accreditation surveys and reviews for NCQA and URAC.
Education
2001- 2003 Chapman University Sacramento, CA
Masters in Health Administration
1999–2001 St Mary’s College Moraga, CA
B.A., Business Administration and Management.
Graduated with honors
Certifications
International Certified Professional in Healthcare Quality (CPHQ)
Certified Case Manager (CCM#33008)
Certified Medical Auditing Specialist. (CMAS)
Interests
Music, computers, reading, writing short stories, poetry and prose
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