Utilization Management Health Care

Sharon F. Clark, BSN, RN,CPC

***** *** ***** ****

Denton, Maryland 21629 Cell: 410-***-****

******@*******.***

CAREER PROFILE

A registered nurse with over 40 years of technical expertise in health care evaluation and improvement. Extensive experience with public and private sector managed care programs including program evaluation in all major health care settings.

Managed Care - Over 7 years of direct experience in quality management and implementation and oversight of the Annual HEDIS Performance Measurement process. Other related work includes implementation of multiple review systems/processes including Interqual Criteria, MeDecision, eDischarge, NCQA standards, HEDIS reviews, EPIC and Case Management practices.

Healthcare Utilization Management - Coding and DRG Validation, Claims audits, medical necessity peer review and fraud investigation. Over 20 years working with national criteria protocols including Interqual© and Millman including care management enterprise systems. CPC certified.

Federal and State Government Contracting - Experienced in quality assurance, claims validation, performance measurement and Medicaid fraud evaluation that included direct work with providers such as hospitals, skilled nursing facilities, long term care facilities, DME companies, and home health agencies

Project Management - Experienced in operations including direct oversight of utilization and quality programs that includes Medicare, Medicaid, and commercial members.

Professional Experience

JHHP Director of Utilization Management 5/16/2022

Responsible for the Utilization Management (UM) functions for Health Plan membership and four lines of business.

Provides strategic direction and oversight of the day-today operations of the corporate utilization management function(s), ensuring that activities are appropriately aligned with mission objectives and strategic imperatives

Provides day-to-day direction to UM staff including maintenance of adequate staffing, assurance of adequate staff training and ongoing education, and direction of the operations of the referral management, telephonic and onsite utilization management activities, and prior authorization functions inclusive of the timely notification of high quality decisions.

Directs and develops the UM program annually and ensures the success of UM functions through medical review and prior authorization, behavioral health management, clinical intake, and inpatient and outpatient nurse review.

Directs and develops specialty programs to support and ensure success of the UM program, inclusive of innovative programs that emphasize and utilize hospital collaborative work relationships, and internal and external partnerships. Ensures compliance and administration of utilization policies through cost effective management of UM operations.

Serves on various Committees inclusive of QI, CM and UM Committees

Serves as liaison to the participating hospitals.

Develops, secures approval and monitors and reports on area operating budget; forecasts spending levels, staffing requirements and resource needs for area.

Develops and enhances program annually.

Analyzes area-specific data to identify trends and opportunities to improve quality of care and/or delivery of services.

Develops and directs innovative utilization management programs/models that improve our membership care costs, care quality, care efficiency, care access and care service.

Participates in new systems selection and directs new system testing and implementation for successful utilization management Integration

CareFirst BCBS, Owings Mills Maryland 5/10/2021-5/15/2022

Senior Nurse Review Auditor

Support the prevention, reduction of and/or recuperation of losses to CareFirst through the clinical review of medical records/claims resulting in savings and/or recover of funds. Responsible for providing clinical knowledge to the SIU team to support both prepayment reviews and/or post-payment investigations.

oReview and investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records in the pre or post payment environment.

oProvide a detailed analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing or reimbursement knowledge.

oMaintain appropriate records and supporting documentation regarding findings in accordance with departmental standards.

oProcess all assigned claims or batch case reviews within departmental and communicated timelines.

Provide support to investigative teams as they perform all levels of healthcare FWA investigations.

Collaborate with investigative teams to correlate review findings with appropriate actions.

Act as liaison/consultant inside the corporation on cases in collaboration with other areas of the company and agencies outside the corporation, as needed.

CGS INC, Nashville Tennessee

Medical Review Manager Home Health and Hospice J-15 8/2020-4/12/2021

Managed day-to-day operations of the Home Health and Hospice Review team for the J-15 contract, with oversight of review, and support staff. Coordinated review activities through all phases of the initial review including referrals to the Medical Director. Key member of the development team for a combined case mgt system across all review areas, and development of the post pay review process.

Total Triage, Utah 8/2019-1/2021

Triage Nurse

Responsible for triaging incoming phone calls from providers, patients, families regarding home health or hospice care concerns. Completed calls for all compact states and Vermont.

Utilized policies and procedures for each provider to support care instructions regarding medications, wound care, symptom management, disease progression. Utilized critical thinking to decide whether a visit was necessary for the patient. Documented thoroughly the discussion and outcome of the call.

Averaged 6-7 calls per hour, based on the call complexity and patient or family needs. Contacted liaisons on call for the providers and worked to develop a successful care plan for their clinical issues. Contacted all staff as necessary to care for the patient, including social workers, MD’s, NP’s, volunteers, administrators, nurses, nursing assistants, family members.

Successfully met the performance indicators for volume and QA review

Compass Hospice, Centreville MD 2019

PRN Hospice Nurse

Completed patient visits as assigned to provide support services and end of life care (this included private homes, assisted living facilities and Hospice Inpt center). Covered three counties and averaged 8-12 patients per shift.

Administered medications as ordered by the MD, provided wound care, set up O2, and completed daily assessments.

Completed admissions to Hospice and pronouncements.

Provided support to patients, families, and friends, as necessary. Involved other clinicians as necessary i.e, social workers, case managers, chaplains, or volunteers.

Documented in computer system all findings and care provided at each visit. Updated care plans based on Hospice guidelines and requirements.

AdvanceMed, Richmond VA

Medical Review Manager 8/2015-3/2020

Managed coordination of the medical review audit process for the CMS ZPIC, UPIC and PERM Contracts. Worked directly with the medical director, claims analyst, coders and field investigators across the states to coordinate fraud medical record review investigations.

Met performance metrics by achieving and exceeding expected contract performance goals

Organized cross training for staff to enhance fraud investigations and their medical review skills. This benefited the contract as well as their individual professional goals.

Enhanced the medical review orientation program with mentors and cross training.

Implemented the new PERM contract as the Medical Review Manager. This included writing policies and procedures, developing the training plan, interviewing and hiring the medical review staff, training the new staff and implementing the actual claim reviews

Delmarva Foundation, Easton, Maryland

Project Director 5/2014-5/2015

Led review operations of the Maryland Medicaid Utilization Control contract. This encompasses both the Medicaid Acute and Long-Term Care contracts. Responsible for contract budgeting, financial performance, accreditation certifications, and development and implementation of review programs.

Successfully led URAC accreditation team and obtained accreditation for our Medicaid Utilization Review programs

Streamlined review procedures and processes to improve efficiency and effectiveness

Health Integrity, Easton, Maryland

Deputy Director/Medical Review Manager 5/2010-5/2014

Managed operational oversight and coordination of the medical review audit process for the CMS Medicaid Integrity Contract. Worked directly with the medical director, claims analyst, coders and field investigators across 34 states and the District of Columbia to coordinate fraud medical record review investigations.

Obtained award performance fees based on achieving expected contract performance.

Organized coding education for staff to enhance fraud investigation procedures, and of those who attended the 90% successfully completed the coding certification exam

Developed and implemented an orientation program with a 97% retention rate

Peninsula Regional Medical Center, Salisbury, Maryland

Director of Patient Care Management 4/2001-5/2010

Led the hospital utilization and case management programs. Developed systems and practices that met or exceeded departmental goals and financial targets. Assumed fiscal accountability for a departmental budget of over one (1) million dollars.

Implemented electronic review systems for the care coordination department

Implemented McKesson’s Interqual criteria and the use of web based applications

Established the reviewer Internal Validity Program

Delmarva Health Plan, Easton, Maryland ( Purchased by CareFirst BCBS)

July 1994 - April 2001 Utilization Management/Case Management/Disease

Management/Quality Improvement Manager

Led the utilization review programs for inpatient and outpatient services, the referral department, case management department and Quality Review program. Served as the liaison to all facilities and providers in relation to these review areas.

Implemented the HEDIS Review Process and completed actual data collection, and analysis

Worked with providers on feedback from HEDIS results for program enhancements

Established a case management that addressed outliers associated with Emergency Room services program to identify outliers for ER care and case management of these members

Delmarva Foundation for Medical Care, Inc. (DFMC), Easton, Maryland

Ambulatory Review Manager 1992 – 1994

Managed the day-to-day operations of the external quality review contract for the Maryland Medicaid Health Maintenance Organization (“HMO”) contract and the Development Disabilities Administration (“DDA”) contract for the State of Maryland. This included direct day-to-day management of staff and review activities and coordination. Served as a liaison with contractors.

Director of Review Operations 1992

Managed day-to-day operations of the Maryland Medicare Peer Review Organization review, with oversight of administrative, review, and support staff. Coordinated review activities through all phases of the initial review including reconsideration review and preparation of Administrative Law Judge reviews.

Education:

University of Wilmington, Delaware, BSN, June 2010

Macqueen Gibbs Willis School of Nursing, 1984 (Diploma Degree)

Chesapeake Community College, Wye Mills, Maryland, 30 Credits

Previous CPHQ, CCM, ACM, and CPHM accreditations

Professional and personal references available upon request

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