Utilization Review Case Manager
Resume:
PATTIE OLEARY
Supervisor/Manager, Inpatient - Monarch HealthCare
San Clemente, CA
****************@***********.***
To obtain a case management position to utilize my extensive leadership experience, intimate knowledge of the health system, and proven interpersonal skills to best serve the hospital and the healthcare community.
Work Experience
Supervisor/Manager, Inpatient
Monarch HealthCare
January 2016 to Present
Supervises the Inpatient Clinical Services nurses. Responsible for the daily operational activities, interviewing, hiring, and training of employees, appraising performance; rewarding and disciplining employees; addressing complaints and problem resolution. Administer supervisory responsibilities in accordance with organizational and departmental
policies/ procedures, and applicable laws.
• Provides daily supervision of assigned staff.
• Monitor and evaluate employee productivity and performance
• Adjust workflow and responsibilities according to business and operational needs.
• Actively participates in the ongoing development of the Inpatient Clinical Services department.
• Provides orientation and ongoing training for new employees.
• Assist with coordination of rates, providers, and other issues for complex cases needing
• out-of-network care.
• Provides after hours assistance with transfers and authorizations Director of Case Management
Foothill Regional Medical Center
September 2014 to December 2015
Foothill Regional Medical Center is a new acute care hospital in Tustin; There are 77 med/surg, 13 ICU bed facility.
• Direct responsibility to implement a case management program at a new acute care facility. Hiring staff to meet the needs of the hospital, while ensuring the highest quality care and services.
• Responsible to create' policy and procedures that meet the standards for condition of participation and accreditation programs. Developing policies to address strategic objectives, including an effective Utilization Review Plan and Discharge planning process.
• Directly responsible for preparation for state licensing survey and Healthcare Facility Accreditation Program and CMS validation survey for the case management process. Including crosswalks for each standard and how we meet each standard.
• Establishing a Quality Assurance program with Performance Measurement indicators that complies with all State, Federal and regulatory agencies.
• Developing a process for proactive discharges, preventing delays in service and minimizing avoidable days. Identifying early in admission high risk patients avoiding re-admissions.
• Collaborating with interdisciplinary team daily, including CEO and medical director to discuss GMLOS, utilization of resources.
• Reporting quartile data and metrics, over- underutilization at Utilization committee. Manager UM/QM/CM Heritage Healthcare
Saint Joseph Healthcare
May 2013 to September 2014
• Direct responsibility for the management of staff providing the services of Care Management, Utilization Management, and Quality Management for the HMO population. Communicating with the staff to convey health plan, contract or operations information to ensure consistent and appropriate knowledge base to perform duties.
• Implemented a Case Management program specific to the Special Needs Program for seniors in the Southern Region. This entailed the recruitment and education of staff to follow specific CMS regulatory process and assuring policy and procedures are adhered to and modified to address changing objectives.
• Responsible for the collection, analysis and reporting of data relevant to care management regarding transition of care and assessment of members.
• Providing staff with standards of performance, providing direction, setting clear expectations, coaching and motivating, facilitating effective communication and fostering an environment of continuous improvement.
• Responsible for writing Case Management and Utilization work plan, establishing goals and targets with collaboration of Medical Director. Monitoring and evaluating, on monthly basis, the CM program for effectiveness. Looking at the Utilization work flow for productivity and turnaround time of referrals for compliance. I also analyze the over or under utilization of our over 150 providers in the southern network.
• Write QM work plan and track grievances and appeals of Health plan members.
• Preparation of the Utilization and Quality Committee, conducting staff meetings assuring policy and procedures are adhered to. Developing policies to address strategic objectives.
• Prepared/participates in all Utilization Management delegation oversight health plan audits. In the past year I have successfully shown compliancy with all mandated regulations, scoring in the 95 percentile with all audits.
Department Manager Mission Hospital 2007-05/13
Care Management
• Manage case management functions, utilization review, and discharge planning for 3 uniquely different campuses, Mission Hospital, Mission Hospital Laguna Beach and Children's Hospital at Mission
• Engage staff in collaborative goal setting based upon job expectations and performance standards in order to complete evaluations of all staff
• Conduct departmental meetings and facilitate effective communication. Promote a work place environment of positivity, dedication, and service
• Collaborate with Medical Director and Leadership to ensure proper utilization of resources
• Collect quantitative data to prepare for and attend quarterly Quality Leadership Committee meetings
• Recruit, select, train and mentor new employees
• Maintain a flexible schedule for the care management department based on census and hospital needs
• Proactively communicate with insurance providers to minimize denials, manage staff compliance with payer expectations and meet compliance expectations for RAC
• Effectively investigate and respond to provider and patient grievances Case Manager
Mission Hospital Acute Rehab Unit
2003 to 2005
• Responsible for assessing and evaluating all admissions to the unit, communicate with patients and families regarding authorizations and admission process
• Provide daily updates for compliance in 100% of insurance authorizations
• Responsible for providing quarterly quality reporting and preparation for CARF survey (in which Mission ARU received 100% certification)
Clinical Manager
Mission Hospital Transitional Care Unit
1997 to 2005
• Responsible for managing daily operations on a 24 hour basis and ensured all staff and facility operating within state regulations (100% complaint with State Regulations)
• Responsible for assessing and evaluating all admissions to the unit, communicate with patients and families regarding authorizations and admission process
• Conduct departmental meetings and facilitate effective communication. Promote a work place environment of positivity, dedication, and service Education
Bachelors of Science in Nursing
Grand Canyon University
2019
Diploma in Nursing
St. Vincent's School of Nursing
Additional Information
Technology Skills
Proficient in Microsoft Office Suite, Meditech, ECIN Allscripts, Milliman and lnterqual Guidelines, Chart Max, and familiar with IDX
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