Case Management Utilization

MARY ROSE DULAY, BSN, LPN

EXPERIENCE

NYSCHRO/MedReview, New York, NY 2009 -Present

Utilization Management Nurse

• Monitor and evaluates the quality and appropriateness of healthcare being provided to our clients’ members.

• Knowledgeable about different insurance products such as PPO, EPO etc.

• Perform Utilization review -pre-authorization and retrospective review as needed for outpatient services and pre-determination review for services or level of care requiring authorization according to the market requirements and policies.

• Identifies high dollar cases and catastrophic cases and make an appropriate referral to Case Management.

• Document in accordance to Med Review documentation standard including HIPAA regulations.

• Ability to handle multiple task and variable case load, creative problem solving and willingness to work as a team member.

Amerigroup Community Care, New York NY 2008 -2009

Amerivantage Medicare Case Manager

• Performed comprehensive case management to members receiving Medicare, following established Amerigroup Care Management policies, procedures and protocols.

• Oversees the coordination and delivery of comprehensive, quality healthcare and services for members with Medicare in a cost effective manner and in concert with the member, PCP and all applicable resources and all regulatory agency requirements.

• Maintains comprehensive case notes on all members in the medical management system, as well as other applicable files.

• Assists all Amerigroup departments with the resolution of the member's problems related to utilization management issues.

• Conducts medical record reviews as appropriate to case management functions and post discharge calls on all members discharged from the hospital to evaluate for case management.

• Intake all requests for outpatient services (DME, Ambulatory, Home care and community referred SNF).

• Issue denials based on medical necessity and CMS guidelines. Health Plus, Brooklyn NY 2007-2009

Patient Nurse Care Coordinator

• Utilizing the Nursing Process reviews and evaluates all clinical services provided to members for Outpatient Services which include Authorization and Pre-certification of ambulatory services.

• Reviews, evaluates, and authorize all requests for extramural referrals, outpatient procedures and ambulatory surgery according to Health Plus UM guidelines and standards.

• Refers cases that does not meet Outpatient standards or where is there is a quality-of-care concern to medical director for review.

• Assesses and coordinates referrals for inter hospital transfer, specialty care, DME, HOME HEALTH CARE, and member transportation .

• Extensive telephonic communication with providers, including Primary Care Providers, Home care and Rehab departments to coordinate care for members, assisting providers in accessing services, providing educational support to providers to facilitate compliance with members' treatment plan.

• Perform telephonic pre certification and concurrent review for Medicaid & Child Health Plus members. Greenwich House, New York, NY 2005-2007

Per Diem Nurse

• Case Manage HIV/TB adult population including health education and medication administration as well as ensuring patients compliance with treatment regime.

• Triage HIV/TB adult population for appropriate nursing intervention. AmeriChoice UnitedHealth Care Inc., New York, NY 1998-2005 Prior-Authorization Nurse (1998 -2003) Call Center Case Manager (2003-2005)

• Performed precertification, concurrent review/utilization management and case management for HMO, Medicaid, and Medicare patients.

• Supervised after office hour's call center and customer service staff.

• Recommended and initiated appropriate alternative settings to meet members' health needs.

• Acted as a liaison/consultant for medical related issues to internal and external customer/clients.

• Determined approval or denial based on medical necessity, M&R and ISP guidelines in compliance with internal policies and procedures.

• Utilized knowledge of DRG, ICD-9, CPT -4 codes to accurately enter data in the Utilization Management System in compliance with state/federal mandates.

Lafayette Methadone Maintenance Program, New York, NY 1998-2005 Per Diem, Staff Nurse

• Provided primary nursing care to chemically dependent patients in a specialized outpatient clinic in the Methadone Maintenance Treatment Program servicing a RN-positive population.

• Responsibilities included triage, intervention for rapid symptom reduction and medications management as well as conducted support groups and provided mental health education including medication and disease management.

• Functioned as a charge nurse on a rotation basis. Blue Cross / Blue Shield Health Center, Jersey City, NJ 1994-1997 Staff Nurse

• Provided primary and emergency care in all areas of subspecialties such as Medical/ Surgical, Pediatrics, and Geriatrics, high risk OB/GYN, and psychiatric care in an ambulatory care setting.

• Responsibilities included triage of patients for assessment and intervention of patient status and provided medication management.

• Provided health education as well as referred for case-finding and utilization review to undeserved and

• marginalized inner city population.

EDUCATION

United Doctors Medical Center, Manila, Philippines Bachelor’s Degree in Nursing, BSN 1977-1981

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