Case Manager Patient Care

Lynda Van Dierendonck R.N.

lvandie** @ yahoo.com

Direct 734-***-****

Address: ***** ***** **** ****** ***, MI 48138

OBJECTIVE

Seeking a position that offers opportunity to utilize and expand on my 27 years’ experience as a Registered Nurse, and business professional within inpatient and Insurance settings.

Professional Profile:

● Case Management in Acute care and telephonically in Insurance settings for commercial, Medicare and Medicaid plans/members with high level of proficiency

● Utilization Review and Management with high proficiency with Appeals and Denials Management with low to moderate proficiency.

● Inpatient Registered Nurse in various Critical Care settings including neonates, OBS and ER.

● Excellent interpersonal skills and communicator

● Excellent organizational skills

● Time Management

● Motivational Interviewing

● Leadership responsibilities and experience

● Quality Assurance/Quality Control

● Telephonic experience

● Critical and Analytical Thinker

● HIPAA standards/compliance proficiency

● CMS, MPRO and JHACO with standards/compliance proficiency

● Expert knowledge proficiency of disease processes and management

● Nurse facilitator for hospital UM/UR committee with Physician Leader Co-Facilitator.

● Training/Development experience

● Mentor Trainer and Preceptor in variety of settings

● Participated in, and assisted in developing the “Hospital Throughput Committee”, reporting directly to the CEO (Henry Ford Wyandotte Hospital), with corporate leadership and department wide administrative staff to markedly improve member ROI with focus on increasing customer experience from the Emergency room to discharge with resulting improved Press/Gainey Satisfaction Scores and increased revenue capture by significantly reducing length of stay

● NCQA Q17 accreditation with 100% Case Management score for 2015 in BCBSM Medicaid Plan Blue Cross Complete (First year of program within BCBSM)

● Successfully planned and implemented hospital dedicated Observation Unit, with unit manager and HIS partner. Successful (100%) quality compliance to CMS Guidelines during first year of operation. Trained and audited Nurses and Physician Providers through developing (with HIS partner and unit manager) and utilizing tool which captured metrics for compliance, and aggregate areas for improvement. Provided goal-based education and feedback with positive response measured in metrics

● Computer competent in multiple system applications and software, Nurse facilitator for hospital UM/UR committee per Medicare guidelines and remained responsible for this team with direct reporting to hospital UM/UR committee per Medicare guidelines and remained responsible for this team with direct reporting to administration and provider aggregate date and recommendations for application improvement

naviHealth

Appeals and Denial Coordinator

11/2021-present

Skilled Inpatient Skilled Care Coordinator

03/24/2019 – 11/2021

Performed weekly functional assessments and engaged the PAC inter-disciplinary care team providing them with the proprietary nH Outcome tool to align expectations for discharge planning. Engaged patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, was responsible for ensuring efficient, smooth, and prompt transitions of care.

·Performed Skilled Nursing Facility (SNF) assessments on patients using clinical skills and appropriate measurement tools, such as nH Predict, nH Outcome, InterQual and CMS criteria, upon admission to SNF and periodically through the patient stays.

·Review targets for Length of Stay (LOS), target outcomes, and discharge plans with providers and families.

·Completed all SNF concurrent reviews, updating authorizations on a timely basis.

·Collaborated effectively with the patients’ health care teams to establish an optimal discharge. The health care team includes physicians, referral coordinators, discharge planners, social workers, physical therapists, etc.

·Assured patients’ progress toward discharge goals and assist in resolving barriers.

·Participated weekly in SNF Rounds providing accurate and up to date information to the naviHealth Sr. Manager or Medical Director.

·Assured appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services.

·Engaged with patients, families, or caregivers either telephonically or on-site weekly and as needed.

·Attended and facilitated patient/family care conferences.

·Assessed and monitored patients’ continued appropriateness for SNF setting (as indicated) according to InterQual criteria or the nH Outcome.

·When naviHealth is delegated for utilization management, reviewed referral requests that cannot be approved for continued stay and are forward to licensed physicians for review and issuance of the NOMNC when appropriate.

·Coordinated peer to peer reviews with naviHealth Medical Directors.

·Supported new delegated contract start-up to ensure experienced staff work with new contracts.

·Managed assigned caseload in an efficiently and effectively utilizing time management skills.

·Entered timely and accurate documentation into the CM Tool application.

·Daily review of census and identification of barriers to managing independent workload and ability to assist others.

·Reviewed monthly dashboards, readmission reports, quarterly, and other reports with the assigned Clinical Team Manager, as needed, to assist with the identification of opportunities for improvement.

·Adhered to organizational and departmental policies and procedures.

·Maintained confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws.

·Performed other duties and responsibilities as required, assigned, or requested

Molina Health Care of Michigan

Care Review Clinician II SNF/IPR/LTAC

12/28/2016 to 03/23/2019

Provided concurrent review and prior authorizations according to Molina policy for Molina members as part of the

Utilization Management team for Medicare, Dual, Medicaid and Marketplace members

•Demonstrated ability to communicate, problem solve, and work effectively with people.

•Highly Proficient with InterQual, MCG and other references for length of stay and medical necessity.

•Knowledge of applicable state, and federal regulations.

•Maintained professional relationships with provider community and internal and external customers.

•Identified appropriate benefits, eligibility, and expected length of stay for requested treatments and/or procedures.

•Analyze clinical service requests from members or providers against evidence based clinical guidelines.

•Processed requests within required timelines

•Refered appropriate cases to Medical Directors and presents cases in a consistent and efficient manner.

•Appropriate referrals to other clinical programs

•Collaboration with multidisciplinary teams to promote Molina Care Model

•Adhered to UM policies and procedures.

Worked with physician partners and multidisciplinary team members to develop a plan of care for each assigned patient from admission to ACH through discharge to SNF/LTAC/IPR. Assess members for care needs, and develops treatment plan with practitioners, providers, members, and support system. Ensures quality member care is provided. Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations. Assesses and responds to patient/family needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care.

Collabra Employment Agency- Assignment to Molina Healthcare of Michigan

RN, Care Review Clinician II (Medicare) Utilization Management

08/2016 to 12/27/2016

•Provided concurrent review and prior authorizations (as needed) according to Molina policy for Molina members as part of the Utilization Management team.

•Identified appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures

•Completed assigned work plan objectives and projects on a timely basis

•Maintained professional relationships with provider community and internal and external customers.

•Maintained cooperative and effective workplace relationships and adheres to company Code of Conduct.

•Consulted with and refers cases to Molina medical directors regularly, as necessary.

•Complied with required workplace safety standards • Demonstrated ability to communicate, problem solve, and work effectively with people.

•Excellent organizational skill with the ability to manage multiple priorities.

•Worked independently and handle multiple projects simultaneously.

•Knowledge of applicable state, and federal regulations.

•Working knowledge of InterQual and other references for length of stay and medical necessity determinations. Worked with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time. Provided daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with state and federal regulations and guidelines.

Blue Cross Blue Cross Blue Shield Michigan

CATASTROPHINC CASE MANAGER; INTEGRATED CASE MANAGE; /MEDICAID CASE MANAGER (BLUE CROSS COMPLETE)

09/2011 to 05/2016

● Maintained excellent clinical documentation according to departmental guidelines, NCQA standards and nursing standards of care.

● Developed complex Medical and integrated Behavioral Health treatment plans by working with member/designee and

Providers to assure effective, safe, and cost-effective excellent quality of care.

● Responsible for screening children and identifying candidates who met CSHCS guidelines. Conduct comprehensive assessments, develop complex medical health and integrated behavioral health plans of care and safe discharge plans to home or alternate levels of care. Establish collaborative relationships within the LHD, hospitals, DME companies, community resources, and physician’s offices to coordinate care needs for children and adults.

● Conducted psychosocial assessments on admission of member to evaluate patients discharge needs and develop safe discharge plans for the transition to next appropriate level of care.

● Reviewed ongoing status of member regarding established goals and revise plan of care as indicated

● Identified appropriate level of interventions including placements to Skilled Nursing Facilities. Home Health Care and Acute

Rehab by sending referrals, ordering DME supplies, and arranging transportation.

● Maintained knowledge of community, local and federal resources to the underinsured.

● Educated member and families regarding insurance benefits and managed care issues.

● Coordinated and educate regarding medication assistance and adherence to diverse population.

● Provided community resources information to members and families (i.e. Counseling, chore providers, and respite care).

● Acted as liaison and advocate between physicians, members, families, community resources and vendors.

● Applied appropriate Inter-Qual criteria to the utilization review.

● Conducted continued stay reviews as requested for payer.

● Conducted utilization reviews for the level of care on admissions for patient according to policy. (Including inpatient acute,

IPR, SAR/SNF and LTAC.

● Maintained clinical documentation according to the agency guidelines, NCQA standards of care as state regulated.

● Collaborated with Medical Consultants, Medical Directors, and Professional Team to ensure seamless progression of care.

● Worked with multiple disciplinary teams, internal and external and manage care coordinators.

● Communicated and coordinated clinical review information to Utilization Management Coordinators when necessary.

● Analyzed clinical reports utilizing approved standards and documents results attained.

● Conducted patient home visits to guarantee that the setting is safe and that medically necessary services are being

delivered and that treatment goals are realistic and attainable on an as needed basis.

● Performed clinical review of claims to ensure that correct reimbursement for covered and/or approved services occurs.

● Experience with Children’s Special Health Care Services including collaborating directly with The State Of Michigan for Case Management with this population

Detroit Medical Center- Harper/Grace Hospital

NURSE CASE MANAGER

06/2009 to 9/2011

● Managed patient load of up to 80 patients a day mixed payer load, including new Medicare, Medicaid HMO and commercial patients needing initial assessments, chart reviews per Inter-Qual, some payers required calls within 1business day or would issue a denial. We would be responsible for these denials administratively as well, following them thru in another software system, for the initial phase of the denial.

● Met daily with hospital CEO, my Director, Lead Case Manager and other key individuals on units to develop strategies’ and make phone calls to Attending Physicians to appropriately expedite patient plan of care.

● Collaborated with MLSW partner to ensure a safe and successful discharge to home or other next level of care with appropriate support system.

Henry Ford Wyandotte Hospital

CLINICAL DECISION UNIT/ EMERGENCY ROOM STAFF NURSE

04/2007 TO 01/2009

● Direct patient care of up to 7 patients including intermediate holders and observation patients requiring telemetry

● Preparation for various stress tests and expedition to next level of care. Aftercare and medication teaching

● Administration of meds including IV and site management

● Acted on multidisciplinary team for discharge planning

● Administered blood transfusions

● Provided all direct care to holding stable CCU/ SICU patients care due to critical bed shortage on floors.

● Educated on Advanced Directives and Patient Advocate

● Performed Advanced Adult Life Support to critically and acutely ill patients, updated families as appropriate.

● Initiated organ donation discussion and procurement

● Provided Behavioral Health Crisis Intervention and assisted placing in appropriate settings

● Initiated and maintained critical care infusions including IV nitroglycerin, insulin, vasoactive gtt’s responding to titration needs.

Henry Ford Wyandotte Hospital

APPEALS DEPARTMENT, FINANCIAL CASE MANAGER, INPATIENT CASE MANAGER for MEDSURG AND ICU/CCU. PRECEPTER AND TRAINER

12/2000 TO 04/2007

● Possess working knowledge of CMS (Center for Medicare Services), MPRO (Michigan Peer Review Organization), HAP (Health Alliance Plan), Medicaid payers as well as commercial insurances payers, JCAHO (Joint Commission on the Accreditation of Healthcare Organizations, and MDCH (Michigan Department of Community Health).

● Manage financial/payer-based correspondence including reviewing payer denials of inpatient and certain outpatient claims. Wrote detailed letters or met directly with payers and insurance companies to address and solve issues affecting revenue recovery within contract and/or CMS guidelines.

● Resource/preceptor for the 25 + members of the Case Management department, including Registered Nurses and Licensed Social Workers, on dealing with payers.

● Facilitated the Clinical Effectiveness Team which reported directly to the Hospital Quality & Safety Committee ensuring the continued compliance with CMS and JCAHO.

● Facilitated the Length of Stay Committee which also included Administrators and Staff Physicians to determine patient movement to appropriate level of care.

● Developed, analyzed, strategized, and reported aggregate “Track and Trended” denial and avoidable day’s criteria, reported directly to the CEO, COO and Hospital Safety Committee and Hospital Length of Stay Committee.

● Prepared and hosted all applicable audits.

● Acted as Patient Disposition Specialist in heavy population gridlock situations. This included assessing unit and emergency departments, communicating needs with Physicians, Case Managers, Nurse Mangers, and Administration to determine tactics to move patient to appropriate level of care.

● Assisted with planning and opening dedicated observation unit to ensure CMS compliance.

● Authored and revised applicable department policies to ensure compliance.

● Audited 100% charts and ensured follow thru with ER and OBS Head Nurses to ensure all charts completed by appropriate Physician staff for 100% compliance for 1st year of new OBS unit.

● Utilization manager and reviewer with emphasis on social work and discharge planner role.

● Performed elder and child abuse reporting and management to ensure safe discharge plan.

● Obtained emergency guardianship for patients in various scenarios.

● Assisted with placement/ obtained authorization of both voluntary and non-voluntary patients to the psychiatric unit.

● Guided patients and their families with regard to exploration of discharge resources including Hospice and Palliative Care.

● Expedited transfers of patients to most appropriate level care including LTAC, acute psychiatric care via state and commercial assessment switchboards.

● Preceptor while floor and OBS case manager.

● Educated patients and families in Advanced Directives and Patient Advocates, gave hospital provided booklets and instructed patients and family members. Educated on community, state, federal medication resources and other local resources as we were a mixed case management program with RN’s and MSW’s performing the same functions as utilization reviewers, discharge planners, and social work functions for very complex discharge issues. We all carried out the psychosocial assessment, set goals, and resolution of barriers to meet goals.

Henry Ford Wyandotte Hospital

CORONARY CARE INTENSIVE AND STEP DOWN, STAFF NURSE, Charge Nurse, Preceptor

1998 TO 2000

● Direct patient care of 2-5 critically ill patients

● Provided teaching on aftercare and medications

● Participated in multidisciplinary discharge planning

● Acted as off shift and weekend charge nurse

● Preceptor new RNs to unit for entire orientation

● Certified in critical care, ACLS,BLS

Henry Ford Hospital

NEONATAL INTENSIVE CARE UNIT, STAFF NURSE, Transport Nurse

1995 TO 1998

● Ambulance Transport Team Member.

● Direct patient care of neonates in level III intensive care unit, primary care RN to specific long term babies until discharge

to their discharge destination. Collaborated with entire team including neonatologist, MSW, RT, family, LHD.

● Assisted with care and stabilization of newborn high-risk deliveries and care management of these infants until discharge.

● Taught breast-feeding and techniques to NICU mom’s.

● Instructed parents on aftercare including the use of apnea monitors, ventilators, and other medical with other members of team and family to ensure a safe successful transition home.

● Maintained close contact with Attending Neonatologist’s due to critically ill newborns for stabilization.

● Certified in Neonatal Critical Care.

EDUCATION

Associate of Science Degree – Nursing, graduated with honors, Henry Ford Community College, Dearborn, MI, 1995

Non- Degree Liberal Arts >60 Credits from Wayne State University, Detroit MI 1982-1985

Non- Degree Liberal Arts from Wayne County Community College 1985-1987

Licensing: State of Michigan Registered Nurse License active since 08/1995.

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