Care Manager and Clinical Analyst with Payer Experience

Becky Ault, RN, CCM

** ***** **** **., *** B-**, North Salt Lake, UT 84054

Cell: 860-***-**** E-mail: ************@*****.***

Qualifications

Effective disease and case management with Medicaid, Medicare, Workers Compensation, and disabled populations. Extensive expertise in utilization review and medical record reviews. Excellent clinical experience in hospitals, home care, hospice, and public health. Led managed care organizations to successful NCQA and JCAHO accreditations. Computer experience with word, excel, outlook, and various systems as required by employers. Excellent verbal and written communication skills.

3/20 – 4/22 AMERIGROUP/ANTHEM

Care Manager for Medicaid members of all ages who need medical care coordination and social needs (housing, food, transportation). Prevent readmissions and direct to medically appropriate level of care.

3/18 – 3/20 INTEGRA

Case Manager for medically complex Medicaid members for coordination of care and link to community resources to prevent readmissions and provide improved access to care. Teach self-care.

9/17 – 2/18 – IPRO

Senior Clinical Analyst supporting contracts with the State of New Jersey including audits of managed care organizations, medical chart abstraction for studies, care management, and QI projects.

11/15 – 12/16 – Complex Care Solutions

Telephonic case management for Medicare recipients in Connecticut. Coordinated all medical needs and partnered with Social Workers to address financial and social needs.

1/12 – 9/15 – McKesson

Case management in Connecticut for the Community Health Network contract. Telephone and field visits. Education for improved self-care, coordination of medical care, provided basic services such as housing, food stamps, DME, and community resources.

8/11 – 1/12 – Gentiva

Home care nursing to patients in northwest Connecticut. Wound care, medication management, DME, referrals to specialists, PT, OT, ST, and LCMSW.

2000 – 2011 – Samaritan North Lincoln and Samaritan Pacific Hospitals

Clinical Hospice Coordinator: Did all quality improvement activities for Hospice, and marketed Hospice services. Carried a full caseload of Home Health and Hospice patients.

Human Resources: Responsible for all professional recruiting (CEO, CFO, Physicians, Nurses, Rehabilitation, Lab, Managers, Directors, all licensed staff, locum tenens placements).

QI/RM Director: Led two critical access hospitals to achieve JCAHO accreditation, Responsible for utilization review, discharge planning, satisfaction surveys, complaints and appeals. Attended all Medical Staff committees at both hospitals to report Core Measures and promote interventions.

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1999 – 2000 – CIGNA Healthcare of Texas

Statewide Director – Quality Management: Aligned separate QM programs (Houston, Dallas) into statewide organization including QI indicators, policies and procedures, staff resource management, and all quality initiatives. Created QM program to apply for NCQA accreditation as one organization in 6/2001. Maintained 3-year Dallas accreditation with an increase of 7% in HEDIS scores; brought Houston office from one to three year level.

1996 – 1999 – NYLCare/AETNA

QI program, NCQA accreditation, HEDIS, Risk Management, credentialing, oversite of Houston office and 5 satellite offices in Texas, transitioned management during AETNA merger.

1995 – 1996 - Prudential

Manager UM/QI: Developed UM and QI programs, NCQA accreditation, HEDIS, all UM and QI activities in Amarillo, Beaumont, Corpus Christi, and Rio Grande Valley. Directed RNs in all cities listed.

1989 – 1995 – United HealthCare

Director of Health Services – Salt Lake City: UM, Customer Services, QI, all transplants case management, NCQA preparation, and Physician Advisory committees.

Supervisor Inpatient Medical Services – Minneapolis: Management of all inpatient admissions with 19 concurrent review RNs covering the entire state.

1988 – 1999 – Crawford and Company Rehabilitation Branch Manager

Opened office in Salt Lake City (medical and vocational). Developed marketing, case management, all reporting for state of Utah; grew office adding additional staff.

1985 – 1987 – Intracorp

Medical Unit Supervisor: Supervised 16 RNs in rehabilitation case management in Utah and the western states region. Did direct marketing to large accounts. Carried catastrophic medical caseload.

1973 – 1985

Ten years hospital nursing (all departments), public health nurse, home health, hospice, respiratory clinics.

Current Licensure: New Jersey

Certificates: Certified Case Manager - CCM

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