Manager Management
Resume:
Lisa Blackford, RN, CCM, CDMS, MHA
El Segundo, CA 90245
**************@*****.***
www.linkedin.com/lisablackford
Objective
Obtaining a hand on case management position that will allow me to use my skills in Workers’ Compensation Case Management including communication with injured workers,
employers, medical providers, and claims adjusters/examiners to establish a case management plan that addresses RTW, modified and full duty, and medical treatment plans which need to be evaluated on an ongoing basis to assess progress towards achieving a case management goal.
SUMMARY
Certified Registered Nurse Case Manager with expertise in reviewing new cases and referring them early to appropriate departments including Case Management; Disease Management; Utilization Review; and other resources based on review of clinical information and medical history
Intercare Insurance Services 2012
RN Case Manager/Supervisor
Reports directly to the Manager for Managed Care. Under the direction of the Manager is responsible for the overall work product of a medical unit
compromised of UR Coordinators, UR Nurses, and Medical Case Managers who are assigned claims files for triage, utilization review, and telephonic case
management. The unit also includes Medical Management Coordinators who are responsible for providing clerical support to the Medical Unit. The nature of
the work involves coaching and counseling, monitoring work performance to assure compliance with company standards and Labor Code rules and regulations,
conducting performance evaluations, and instituting corrective action when appropriate.
Performs monthly audits of 5-10% of claims for the purpose of validating accuracy and completeness of the UR and/or Nurse Case Management process including
outcomes
Works with Medical Director to ensure compliance with guidelines for Utilization Review.
Maintains production performance and savings reports for management review and information.
To perform the job successfully, an individual should demonstrate the following competencie”
Project Management
Change Management
Leadership
Managing people
Must be self-motivated with ability to multi task and adapt to changing working priorities
Must have strong organizational skills with attention to details
Must have strong time management skills
Genex Services
Telephonic Case Manager 2011
Contracted position as a Workers’ Compensation telephonic case management. Provided
Medical and Disability case management services to injured workers. Duties included
ongoing communication with injured workers, employers, medical providers, and claims to develop case management plans that addressed RTW goals and medical treatment goals. Utilized guidelines such as ACOEM, MTUS, McKesson, and Presley Reed. Met time frames for
goals as well as followed clients special handling instructions to achieve success in achieving case management goals.
Anthem Worker’s Compensation Managed Care Services 2003 - 2010
Manager ll, Managed Care Services
Supervised staff of 14 Registered Nurses who performed case management and utilization review on client referred cases. Responsible for quality assurance, appropriateness of referrals, and nurse productivity in order to achieve anticipated outcomes and meet client expectations.
Within first year, team received company recognition award for excellent service provided.
Quality improvement needs identified through review of files. Identified training needs and results improved with Quality Review scores resulted above goal of 90 %.
Used evidence-based criteria to achieve scores > 90% on state of CA utilization review audit. One client office received results of 100%.
Regularly communicated with claims examiners and vendors. Ensured cases were appropriately channeled to contracted providers. If there were difficulties with contracted providers not following terms of their contracts, files were reviewed to make sure cases were being referred to complaints and grievance.
Obtained URAC 3 year accreditation on each URAC visit
Liberty Mutual Insurance Company, Orange, CA 1994-2003
Manager of Medical and Disability Case Management
Identified cases to identify cases that could benefit from case management services. Worked with home office catastrophic unit on all catastrophic cases. Assigned nurse’s field visits as needed. Audited files with claims examiners to identify training need on cases that met case management criteria. Achieved departmental revenue goals; quality assurance goals; and return on investment by reviewing information warehouse reports and file reviews. Was a subject matter expert on an IT project. The purpose of this which was to assist IT in developing a case management system for our department that could provide reports in order to measure outcomes.
Liberty Mutual Insurance, Glendale, CA 1993-2003
Nurse Case Manager
Managed caseload of 40-50 cases to ensure medically necessary care was being provided in a cost effective manner. Attended medical appointments with injured workers to discuss treatment plans and anticipated outcomes. Cases varied from orthopedic injuries to catastrophic cases. Responsible for appropriately determining when field visits were necessary.
Assisted in new hire training for new managed care unit
Handled all UPS cases at Cerritos hub which included monthly visit to UPS occupational nurse to review cases
CNA Insurance 1992-1993
Nurse Consultant handling 40¬-50 medical management cases. Reviewed new referrals within 24 hours and made contact with injured worker within 24 hours and providers and employers within 48 hours. Handled cases telephonically or made field visits to providers to ensure case management goal was achieved. Cases included catastrophic cases such as stuntmen in the entertainment business.
Additional Related Experience
Eagle Insurance Group 1990-1992
Nurse Consultant assigned to identify Centers of Excellence for catastrophic cases. These include long shore and oil rig cases.
Liberty Mutual, Senior Rehabilitation Nurse 1985-1990
File reviews with claims examiners to identify cases that should go to case management early intervention program evaluating all new claims for UPS. Assigned catastrophic claims. Worked with claims and the Home Office Catastrophic Case Management Unit on these types of cases.
Liberty Mutual, Orange
Received Significant Achievement Award (year to year)
Employee of the month 2 years in a row
High Performer Bonus Recognition for implementation of community-based nursing unit
Clinical Experience
Medical-Surgical Experience-White Memorial Hospital and Santa Monica Hospital
Completed EMT Course –Orange County Regional Occupational Center 2006
Los Angeles City Fire Department-Shadowing Paramedics in South Central Los Angeles 2006-2007
Other Activities
Classes at El Camino College-Fire Science; Basic Law; Crime Analysis; and Computer 2003-2012
Volunteer work at Los Angeles County Sherriff’s Department Youth Services Center
Obtained CEU’s through seminars; webinars; and home study courses
South Bay Professional Associations
Pacific Gateway 2012-Professional Development Classes
Lisa Blackford, RN, CCM, CDMS, MHA
1501 E. Walnut Avenue
El Segundo, CA 90245
**************@*****.***
www.linkedin.com/lisablackford
Objective
Obtaining a hand on case management position that will allow me to use my skills in Workers’ Compensation Case Management including communication with injured workers,
employers, medical providers, and claims adjusters/examiners to establish a case management plan that addresses RTW, modified and full duty, and medical treatment plans which need to be evaluated on an ongoing basis to assess progress towards achieving a case management goal.
SUMMARY
Certified Registered Nurse Case Manager with expertise in reviewing new cases and referring them early to appropriate departments including Case Management; Disease Management; Utilization Review; and other resources based on review of clinical information and medical history
Intercare Insurance Services 2012
RN Case Manager/Supervisor
Reports directly to the Manager for Managed Care. Under the direction of the Manager is responsible for the overall work product of a medical unit
compromised of UR Coordinators, UR Nurses, and Medical Case Managers who are assigned claims files for triage, utilization review, and telephonic case
management. The unit also includes Medical Management Coordinators who are responsible for providing clerical support to the Medical Unit. The nature of
the work involves coaching and counseling, monitoring work performance to assure compliance with company standards and Labor Code rules and regulations,
conducting performance evaluations, and instituting corrective action when appropriate.
Performs monthly audits of 5-10% of claims for the purpose of validating accuracy and completeness of the UR and/or Nurse Case Management process including
outcomes
Works with Medical Director to ensure compliance with guidelines for Utilization Review.
Maintains production performance and savings reports for management review and information.
To perform the job successfully, an individual should demonstrate the following competencie”
Project Management
Change Management
Leadership
Managing people
Must be self-motivated with ability to multi task and adapt to changing working priorities
Must have strong organizational skills with attention to details
Must have strong time management skills
Genex Services
Telephonic Case Manager 2011
Contracted position as a Workers’ Compensation telephonic case management. Provided
Medical and Disability case management services to injured workers. Duties included
ongoing communication with injured workers, employers, medical providers, and claims to develop case management plans that addressed RTW goals and medical treatment goals. Utilized guidelines such as ACOEM, MTUS, McKesson, and Presley Reed. Met time frames for
goals as well as followed clients special handling instructions to achieve success in achieving case management goals.
Anthem Worker’s Compensation Managed Care Services 2003 - 2010
Manager ll, Managed Care Services
Supervised staff of 14 Registered Nurses who performed case management and utilization review on client referred cases. Responsible for quality assurance, appropriateness of referrals, and nurse productivity in order to achieve anticipated outcomes and meet client expectations.
Within first year, team received company recognition award for excellent service provided.
Quality improvement needs identified through review of files. Identified training needs and results improved with Quality Review scores resulted above goal of 90 %.
Used evidence-based criteria to achieve scores > 90% on state of CA utilization review audit. One client office received results of 100%.
Regularly communicated with claims examiners and vendors. Ensured cases were appropriately channeled to contracted providers. If there were difficulties with contracted providers not following terms of their contracts, files were reviewed to make sure cases were being referred to complaints and grievance.
Obtained URAC 3 year accreditation on each URAC visit
Liberty Mutual Insurance Company, Orange, CA 1994-2003
Manager of Medical and Disability Case Management
Identified cases to identify cases that could benefit from case management services. Worked with home office catastrophic unit on all catastrophic cases. Assigned nurse’s field visits as needed. Audited files with claims examiners to identify training need on cases that met case management criteria. Achieved departmental revenue goals; quality assurance goals; and return on investment by reviewing information warehouse reports and file reviews. Was a subject matter expert on an IT project. The purpose of this which was to assist IT in developing a case management system for our department that could provide reports in order to measure outcomes.
Liberty Mutual Insurance, Glendale, CA 1993-2003
Nurse Case Manager
Managed caseload of 40-50 cases to ensure medically necessary care was being provided in a cost effective manner. Attended medical appointments with injured workers to discuss treatment plans and anticipated outcomes. Cases varied from orthopedic injuries to catastrophic cases. Responsible for appropriately determining when field visits were necessary.
Assisted in new hire training for new managed care unit
Handled all UPS cases at Cerritos hub which included monthly visit to UPS occupational nurse to review cases
CNA Insurance 1992-1993
Nurse Consultant handling 40¬-50 medical management cases. Reviewed new referrals within 24 hours and made contact with injured worker within 24 hours and providers and employers within 48 hours. Handled cases telephonically or made field visits to providers to ensure case management goal was achieved. Cases included catastrophic cases such as stuntmen in the entertainment business.
Additional Related Experience
Eagle Insurance Group 1990-1992
Nurse Consultant assigned to identify Centers of Excellence for catastrophic cases. These include long shore and oil rig cases.
Liberty Mutual, Senior Rehabilitation Nurse 1985-1990
File reviews with claims examiners to identify cases that should go to case management early intervention program evaluating all new claims for UPS. Assigned catastrophic claims. Worked with claims and the Home Office Catastrophic Case Management Unit on these types of cases.
Liberty Mutual, Orange
Received Significant Achievement Award (year to year)
Employee of the month 2 years in a row
High Performer Bonus Recognition for implementation of community-based nursing unit
Clinical Experience
Medical-Surgical Experience-White Memorial Hospital and Santa Monica Hospital
Completed EMT Course –Orange County Regional Occupational Center 2006
Los Angeles City Fire Department-Shadowing Paramedics in South Central Los Angeles 2006-2007
Other Activities
Classes at El Camino College-Fire Science; Basic Law; Crime Analysis; and Computer 2003-2012
Volunteer work at Los Angeles County Sherriff’s Department Youth Services Center
Obtained CEU’s through seminars; webinars; and home study courses
South Bay Professional Associations
Pacific Gateway 2012-Professional Development Classes
Proficient in Microsoft Office with exception of ACCESS which I am in the process of learning
Contact this candidate