Case Manager Care

Mary Anne Clayback RN, BSN, CCM

Address: **** *. ***** ****., *****, Texas 75093

EDUCATION:

NYS License Number: 307797 through 02/29/2026

1996: BSN Daemen College

**/**/****: CCM

CCMC Certificate Number: 00054563

Renewal Date: 05/31/2025

WORK EXPERIENCE

1996-1998: Sheehan Memorial Hospital. Discharge Planner. Responsible for discharge plan for at risk Medicaid population.

1998-2002: Prison Health Systems, Bluebell PA., Williamsville, New York. Responsible for telephonic inpatient and SCR review, of patients in the NYS DOC system, through contract with the NYS DOC. 2002-2012: Independent Health. Case Manager: Heart Failure Case Manager, Medisource Team Case Manager.

2012-2016: Independent Health. The Primary Connection Initiative, Imbedded Care Manager in 5 Primary Care Office practices. Responsible for the following Accountabilities: 1. Care Transition Process: Support practice’s process in place for Care Transition. 2. PPIA/PPR: Review identified members and assist practice with management. 3. Provide Care Coordination: Assess needs, identify and resolve barriers, facilitate communication between patient, PCP, specialist and ancillary providers. 4. Palliative Care Program: Assist practice with understanding trigger criteria and referral to appropriate services.

5. HCC Coding: support the HCC coding initiatives in the practice. 6. Gaps in Care: Review and communicated gaps in care with office staff during Member intervention.

7. Specialty Steerage: Support identification of opportunities to steer Member care back to PCP services and to Specialists of high performance.

2016-2017: Independent Health. Disease Manager, Chronic Condition Management. Responsible for providing outreach; assessment and intervention, to Level 2, Moderate Risk, Members with Congestive Heart Failure, Coronary Artery Disease, Asthma, COPD and Diabetes. 2017-2023: Independent Health, Senior Case Manager: Responsible for providing outreach; assessment and intervention, to Medicare Members with multiple comorbidities. Responsible for the following accountabilities:

Assess the patient’s broad spectrum of immediate and long-term needs through evaluation of the patient’s social and medical history. Develop a plan of care with providers of care and patients, to identified population along the continuum of care; allied health professionals must stay within their scope of practice.

Provide ongoing assessment and documentation to monitor member’s response to the plan of care; revises as needed based on changes in the member’s condition, lack of response to the care plan, preference changes, transitions across settings, and barriers to care and services. Measures and reports outcomes that demonstrate the efficacy, quality, and cost-effectiveness of case management interventions to achieve goals.

Conduct comprehensive assessments of the member’s health and psychosocial needs; includes health literacy, cultural, clinical and laboratory data, claims history, contract and benefit language, related state and federal regulations, established clinical guidelines, and recent literature or research as appropriate to ensure valid case management decisions. Facilitate communication and coordination between members of the healthcare team; facilitate safe transition of care along the healthcare continuum. Ability to identify cases that would benefit from alternative care through assessment and evaluation of the patient’s needs, as well as available resources. Apply appropriate medical policies to evaluate the medical necessity, appropriateness and efficient use of healthcare services, procedures, and facilities across the continuum of care. Identify and review high-risk cases to ensure members are transitioned to the appropriate care. Document the patient’s plan of care in a timely manner. Employ evidence-based guidelines and other self-management resources to maximize the member’s health, wellness, safety, adaptation, and self-care. Understand case management concepts such as roles, philosophies, principles, liability, and confidentiality issues. Apply these concepts in developing appropriate plan of care and goals based on the needs of the patient.

Improve outcomes by utilizing adherence guidelines, standardized tools, and proven processes to measure a member’s understanding and acceptance of the care plan, his/her willingness to change, and his/her support to maintain health behavior change. Ensure compliance with regulatory standards as indicated; adhere to applicable local, state, and federal laws, as well as employer policies, governing all aspects of case management practice, including member privacy and confidentiality rights. Actively participates in project teams and medical management initiatives as needed. Assist in the orientation of associates as needed. 2024-2025 RN Office Triage Nurse

Location: General Physician PC, 18 Limestone Drive, Suite 5, Williamsville, New York 14221 Responsible for answering clinical calls and assessment of the patient. Triage included appropriate home care advisement, provider referral, and appointment Scheduling. Office responsibilities included working with clinical staff, nurse injections and patient referral and education.

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