TONYA BAIAMONTE MAYER, BSN, RN, CCM

***** ***** ***** ****, ***********, La 70454

504-***-****

adypcp@r.postjobfree.com

PROFESSIONAL SKILLS SUMMARY

Registered Nurse

Highly qualified professional with extensive clinical, staff leadership, and management experience.

22 years of nursing experience across health care settings including hospital, nurse home visits, nursing home visits, managed care, community services, managerial, primary care environments, as well as knowledgeable in hospice regulatory compliance, reporting, due diligence philosophy, hospice and palliative care philosophy, hospice team leadership, documentation, assisting in developing EMR systems, and education.

Strong clinical background, including pediatrics, adult chronic and acute conditions, hematology/oncology, gerontology, and hospice and palliative care with end of life care. Currently training for transplant case management certification.

Communication, interpersonal, and leadership skills with the ability to excel in challenging and deadline driven environments.

Established in patient support including assessment, counseling, education regarding medications and treatment, lab work, discharge planning, documentation with care plan for diagnosis, advocacy, coordinating cost-effective, quality health care, administration of treatment procedures, and patient/family focused positive learning environment.

Computer skilled in Microsoft excel, office, electronic medical records, managing daily patient volume including telephone calls, appointment scheduling, reporting details, auditing, coordination of care, and reviewing details of patient referrals. Proficient in all documentation/record maintenance/paperwork to ensure accuracy, compliance, and patient confidentiality.

Extensive training in Motivational Interviewing techniques and Management skills.

CREDENTIALS

Certified Case Manager

Multistate Nursing License, received in Louisiana

Certified Hospice and Palliative Nurse

Current

Current

Previously Certified

EXPERIENCE

HealthComp, LLC (formerly Gilsbar, LLC) Covington, La

May 2015 to present

Promoted to Manager of Case Management and currently in this position.

Telephonic Nurse Case Manager

Medicare Case Management Team Lead

Assess patients to learn about their needs and goals to create effective case management plans.

Implement, coordinate, and evaluates health related service options while acting as a care advocate.

Maintaining and coordinating cost-effective, quality of care, evaluating progress and adjusting care plan as needed to improve outcomes.

Contact patients regularly to provide health education and addressed service coordination needs.

Assist patients in all aspects of care so that they achieve optimal outcomes in their healthcare journey.

Coordinates medical care with providers, hospitals, and pharmacies on behalf of the patients.

Review clinical records to adjust the patient’s care plan and identify potential service coordination.

Coordinate, assist, and evaluate records with Utilization Review Team to ensure patient is receiving the appropriate level of care.

Performs medical necessity reviews of treatment plans against accredited established criteria utilizing MCG, Cigna Guidelines, and NCCN (National Comprehensive Cancer Network) Guidelines. Refers, discusses, and coordinates cases with the Medical Director as required.

Communicates with other departments within the company, as well as outside the organization per guidelines.

Provides assistance and coordinates needs with discharge planning, educating on all appropriate options for the patient, including but not limited to home health services, rehabilitation services, palliative services and hospice services, ensuring that the patient/family is well informed in their options prior to decision being made.

Review, collects, document, analyze data and outcomes of all aspects of each case.

Writes reports detailing clinical status, claims status, care plans, treatment plans, and anticipated future needs. The reports are presented to health plans, reinsurance carriers, and upper management to notify of potential complicated and/or high dollar claims/services.

Information gathered is measured on a regular basis, with ongoing communication with the member and Health Plan Administrators to determine if desired outcomes are being reached.

Evaluated cost savings by utilizing HCUP data (Healthcare Cost and Utilization Project)

Specialized in managed care for the Medicare population, providing coordination amongst all specialties while promoting ongoing preventive care ensuring patients are receiving high quality continuum of care from preventing acute complications, readmissions, and emergency room visits while following Medicare regulations.

Negotiated high dollar non network claims.

Maintains nursing advocacy for patients at all times.

Independent Hospice Auditor

March 2018 – December 2022 (currently upon availability)

Responsible for auditing hospice charts for specifics related to goals of an assigned project.

Documentation is reviewed to ensure compliance with applicable statutory and regulatory requirements and organizational policies.

Responsibilities may include, but not limited to reviewing submitted documentation for completeness and compliance with technical elements.

Performs audits and measured for compliance of all regulatory elements as defined for hospice services.

Ensure that knowledge of Hospice Regulations and Compliance remains current and is ongoing.

Collaboration with the team is maintained throughout the project.

Data is compiled, documented on spreadsheets, assist in analyzing findings and report results in a collaborative manner.

Types of audits include, but are not limited to audit for due diligence, compliance and regulatory audits, assisting agencies in the opening stages to ensure standards are being met, timely submission of billing for compliance, timely submission of quality improvement and assurance, and CAHPS survey compliance.

Provide recommendations where improvement may be needed in all areas.

Audits completed to date been among several different electronic medical record programs.

New Century Hospice dba Generations Hospice Denham Springs, La

Director of Nursing and Director of Clinical Services

Field Nurse Case Manager

September 2009-August 2015

Began as a field case manager, managing 15-20 pts in homes and nursing homes providing care in accordance with the Physician’s plan of care.

Evaluated patients physical, psychosocial, spiritual, and environmental needs and to ensure the appropriateness according to the Medicare/Medicaid guidelines. Coordinated care with direct communication with the physician and other team members on a daily basis.

After 2 years in the field, promoted to the Assistant Director of Clinical Services.

Responsibilities included triaging patient and family phone calls, accepting referrals and making sure they qualify under Medicare and Medicaid guidelines, obtaining authorizations from private insurances, writing ADRs for Medicare, and Letters to qualify patients for Medicaid, Chart audits and monthly medication reviews.

In January 2013, promoted to Co-Director of Clinical Services and Direct Supervisor of Nursing staff.

In September 2013, promoted to the Director of Clinical Services and Director of Nursing.

Managed, directed and supervised the clinical operations as to ensure high quality client care, safe and professional clinical practice, compliance with State and Federal regulations and organizational policy and procedure.

Coordinate the intake process, obtaining and monitoring inpatient contract/services, and marketing the services of NCH to support growth and revenue.

Assigns, manages, and supervises personnel in accordance with position descriptions and policy.

Performs patient visits and participates in the on-call process as indicated.

Worked closely with QA/PI coordinator, continued with the tasks as mentioned above, and ran the daily operations of the office.

Awarded Employee of the month in 2010 and 2011, Employee of the Quarter in 2012, and 2012 Employee of the Year.

St. Helena Community Health Center School Based Health Center Greensburg, La

April 2006 - September 2009

Staff RN working one on one with a pediatrician in school-based health care center. The center was staffed by 1 RN, 1 social worker and a secretary with a physician 2 times a week and as needed.

Responsible for running and organizing the clinic as being the only nurse in the office.

Conducted KidMed Exams, Comprehensive Exams, illness complaints, record/chart maintenance, immunization maintenance, and collaborative measures with the main clinic personnel, parish school board, school personnel, and other health care professionals, scheduling and coordinating referrals to specialists, parental meetings, individual health plans, pediatric diabetic care and maintenance, hearing and vision screens, as well as other clinical maintenance needs.

Active member of the QA/PI team responsible for the clinic to receive its initial Joint Commissions Certification and ensuring recertification thereafter.

Children’s Hospital New Orleans, La.

May 2000 – December 2005

Worked as a Nurse Tech until December 2000

Upon nursing graduation, hired on as a staff RN in the NICU.

Responsible for caring for level three and level four NICU patients and their families.

Additional Duties in this position include - Charge RN, Preceptor, Educator and Certified as a Transport RN, CPR, PALS, and NRP.

Also assisted Unit Manager in her daily tasks, including staffing and scheduling.

EDUCATION

Nursing School

January1998-December2000

Louisiana State University Health Sciences Center, New Orleans, La.

- Bachelor of Science in Nursing

College August 1996 - December 1997

Louisiana State University Baton Rouge, La.

General Studies/Undergraduate prerequisites in Nursing

References upon request

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