Juliet Duncan
Manager, Medical Management at Community Care Plan- Claim this Profile
Click to upgrade to our gold package
for the full feature experience.
Topline Score
Bio
Credentials
-
2-14 License, Life and Annuities
State of Florida -
RN
State of Florida
Experience
-
Community Care Plan
-
United States
-
Insurance
-
100 - 200 Employee
-
Manager, Medical Management
-
Jun 2016 - Present
Accountable for overseeing case management and utilization review services for the provider service network to determine that treatment is medically necessary and appropriate. Emphasis on ensuring compliance across the continuum of care, continuous process improvement initiatives and alignment with the organization’s mission, vision and values. Manage a staff of 16. ✔ Work closely with the Director of Medical Management, CMO, Medical Directors and Physician Advisors on clinical issues and clinical review and interfacing with external agencies and contracted partners in care vendors. ✔ Gather, analyze and report utilization management data and act as a resource on prior authorization issues. ✔ Ensure appropriate usage of resources to facilitate the utilization management process and ensure compliance with State program guidelines including NCQA and AAAHC. ✔ Act as a role model in demonstrating the customer service standards of the organization. ✔ Deliver employee training for all Medical Management policies and procedures. ✔ Lead and direct overall operations of the utilization management function to ensure consistency of policies/procedures and work flow. ✔ Evaluate utilization management program effectiveness and recommend improvements. ✔ Ensure utilization management targets for all products are met for the annual operating plan, state requirements and financial management. Recognized for attention to detail and ability to contain costs.
-
-
-
Broward Children's Center
-
United States
-
Hospitals and Health Care
-
1 - 100 Employee
-
Director of Nursing, Home Health
-
Feb 2010 - Feb 2016
Responsible for overseeing the clinical care of patients in a home care setting. Planned, organized, developed and directed the overall operation of nursing services in accordance with current federal, state, and local standards, guidelines, and regulations to ensure the highest degree of quality care was maintained at all times. Provided leadership for clinical staff. ✔ Coordinated and case managed all direct and indirect patient services provided by clinical personnel. ✔ Supervised 150+ LPNs and RNs and verified scheduled shifts via Sandata (AHCA Telephonic Verification System). ✔ Successfully compiled and submitted medically fragile pediatric cases for authorization to AHCA via Kepro, eQHealth, and SFCCN. ✔ Ensured the consistent delivery of professional patient care that is based on recognized national standards of practice.
-
-
-
Jackson Health System
-
United States
-
Hospitals and Health Care
-
700 & Above Employee
-
Registered Nurse, CCU, MICU
-
Mar 2008 - Jun 2010
Worked as a key member of the interdisciplinary team providing direct patient care on a 14-bed unit for both STEMI and Non-STEMI patients. Conducted admission of new patients, performed patient assessments, implemented treatment plans, initiated interventions, and facilitated patient and family education. Initiated care and treatment for acute and chronic patients, documented patient files, and administered medications. ✔ Monitored hemodynamics via SwanGanz using FICK or Thermal dilution. ✔ Collaborated with physicians and departmental staff to ensure consistency and quality of care. ✔ Educated patients and families about the disease process, precautions, restrictions, proper medications, and health promotion. ✔ Acted as a patient advocate in order to resolve any patient issues. ✔ Integral part of the continual proactive efforts of quality improvement for patient care. ✔ Provided protocol-driven skilled nursing to patients and family support services utilizing a patient-focused care model.
-
-
-
-
Registered Nurse, ICU
-
Sep 2005 - Mar 2008
Provided direct care to patients on a 24-bed unit. ✔ Observed, assessed, and recorded symptoms, reactions, and progress in patients. ✔ Developed and managed nursing care plans. ✔ Administered medications and treatments as prescribed by a physician or according to established policies and protocols. ✔ Educated clients and their families in proper care to improve or maintain health. ✔ Effectively collaborated with physicians, medical professionals and departmental staff to plan unit activities and ensure quality care. ✔ Ensured adherence to all OSHA, hygiene, JC and HIPAA standards and requirements.
-
-
Education
-
University of South Florida
Master of Science Degree in Nursing Informatics - Expected 2020 -
Barry University
🎓 Bachelor of Science (B.S.) in Management -
CUNY Bronx Community College
🎓 Associate of Science (A.S.) Degree in Nursing -
Miami Dade College
Associate of Science (A.S.) Degree
Community
