Disease Management RN Health Educator

• Nov 2015 - Present

RN Case Manager

• Feb 2015 - Dec 2015

A key member of the Clinical Care Team focusing on patient centered case management. Started the Emergency Room Outreach Program as part of our Care Navigator Initiative to drive members to Primary Care Physicians. Actively reviewed and documented NCQA standards for QI7 and QI8 (Complex and Disease Management). Plays a key role in Utilization Management decisions for clinical appropriateness and benefit coordination. Oversees day to day activities of the case, disease and utilization management teams. Established process improvement initiatives across cross functional teams. Show less

Senior Case Manager

• Oct 2010 - Feb 2015

As a case manager for national accounts, responsible for performing care management within the scope of licensure for members with complex and chronic care needs. Care management includes assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically; licensed to practice in all 50 states. Preceptor for all new employees.Responsibilities include:• Ensuring member access to services appropriate to their health needs.• Conducting assessments to identify individual needs and developing a specific care management plan to address objectives and goals as identified during assessment.• Implementing care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.• Arranging internal and external resources to meet identified needs.• Monitoring and evaluating effectiveness of the care management plan • Developing care management treatment plans together with medical directors and physician advisors• Solving problems regarding providers, claims or service issues. Show less

Disease Management Care Manager

• Oct 2007 - Oct 2010

As a nurse care manager for a disease management company, responsibilities include educating members with chronic conditions (CAD, COPD, Asthma, CHF and Diabetes). Coordinated care with other health professionals (dieticians, exercise physiologists, pharmacists and social workers). Coordinated education according to members’ needs concentrating on individualized goals specific to each individual member. Covered all chronic conditions covered in member’s plan and facilitate members learning to better manage their own health. Contacted providers to facilitate care needs when necessary. Attended medical rounds monthly, sharing ideas and input to other nurses regarding care of other members. Acted as a team player at all times, putting the members first to get the best care and education. Preceptor for new employees. Active on numerous committees. Show less

Home Health Case Manager

• Oct 2001 - Sep 2007

Facilitated case management and served as customer advocate for patient care utilizing strong nursing assessment skills; identified support system and community resource needs; and identified appropriate care. Initiated, taught and implemented care for chronic and acute illness, other disease management needs, IV therapy and various types of wound care management. Identified patient needs, assisted and determined benefit eligibility and/or facilitated community resources to meet the need. Applied regulations and guidelines; accessed insurance benefits; communicated well with all disciplines including insurance case managers, physicians, providers, patients and their families. Coordinated patient and family teaching to promote independent living. Preceptor for new registered nurses. Worked with both Medicare and private insurance patients. Show less