Karen Hilton
Utilization Management Clinician SME at Fidelis Care- Claim this Profile
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Bio
Credentials
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PRI/SCREEN
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Experience
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Fidelis Care
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United States
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Hospitals and Health Care
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700 & Above Employee
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Utilization Management Clinician SME
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Oct 2017 - Present
Utilizes a collaborative review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate decisions regarding medical necessity, pre-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider advocate promoting and coordinating delivery of quality, cost-effective healthcare services based on medical necessity and contractual benifits.Strong quality background,able to identify suspicious trends in requests for potential fraudulent activity. Show less
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Care Manager
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Jun 2016 - Oct 2017
Management of Medicaid members in Managed long term care for home care needs, durable medical equipment ,skilled rehabilitation services,coordination of all home care needs with medical professionals.
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Director of Quality Assurance/ Special Programs
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Feb 2016 - Jun 2016
Responsible for • Manage, supervise, direct and evaluate clinical staff, conduct supervisory joint field visits with clinicians, staff evaluations, case conference with interdisciplinary team. • Clinical record review –tracking and trending areas of compliance • Infection control tracking of clients and employees • Tracking of medication errors • Tracking of falls and injuries of clients and staff with root cause analysis • Tracking client complaints • Track quality issues using Strategic healthcare performance software • Compiling all data and presenting it at the quality improvement committee • Prepping and assisting with state survey • Over see the manager and assignment and distribution of the UAS/PRI requests to special team staff and review UAS documentation to ensure completion is accurate and timely. • UAS/PRI screen assessments for CDPHP, NHTD Waiver, TBI waiver, Fidelis reassessments • Staff education on quality assurance issues and implementing corrective action plans for compliance. • Policy and procedure writing and review • Staff Support for Home Care Home Base EMR • Back office workflow for Home Care Home Base EMR Show less
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Living Resources Home Care Agency
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United States
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Wellness and Fitness Services
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1 - 100 Employee
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Director of Nursing
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Jan 2015 - Feb 2016
Responsible for • Responsible for day to day operations of the agency• Supervision of Registered Nurse case managers• Staff evaluations• Oversight of HHA Supervisor and Training Program for HHA/PCA• Coordination with Intake and Scheduling of Aides• Quality Assurance tracking and over site of Quality committee for LHCSA/CHHA• Over site of Program Committee• Over site of Case management for VNA Options and Prime Health Choice• Over site of the following contracts we supply aides for• VA, NON VA Care, CDPHP, Fidelis, Work mans Comp, Genworth ,VNA Options• Managing back office in Home Care Home Base• Covering scheduling as needed• Pre-enrollment ,enrollment visits for VNA Options home care , Prime Health Choice• Deficient free DOH desk audit• Policy and procedure review and writing Show less
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Quality Assurance Manager /Infection Control/Special Contracts
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Aug 2013 - Jan 2015
• Chart audits –tracking and trending areas of compliance• Infection control tracking of clients and employees• Tracking of medication errors• Tracking of falls and injuries of clients and staff• Tracking client complaints• Track quality issues using Strategic healthcare performance software • Compiling all data and presenting it at quality improvement committee• Prepping and assisting with state survey• UAS/PRI screen assessments for CDPHP, NHTD Waiver, TBI waiver, Fidelis ,reassessments• Development of new employee orientation program• Assisted with set up and implementation of Crescendo and Homecare Home base electronic medical records• Staff education on quality assurance issues and implementing corrective action plans for compliance.• Assisting CDPHP and Attorney General office with Medicaid fraud cases • Over site of medical records department and purchasing Show less
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Nurse Manager
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Jun 2005 - Jun 2013
Responsible for • Management of RN case managers & LPN staff• Employee evaluations• Payroll processing in Lawson • Allocation of invoices in web now• Facility ordering in Lawson• Manager self serve• Article28DT limited pharmacy including vaccines and storage• Medical clinic• Purchasing department• Infection control and safety chairperson • Daily QI/QA & committee work• IPRO Projects for nursing• Tracking Wounds and weekly reporting• Continuing education for nursing staff• OSHA standards for employee safety• Policy and procedure writing• Training and skill assessments for Nurses and home health aides.• Experience with DOH and CMS surveys 2007,2009,2011 no deficiencies in nursing Special projects:• Computerized home health aide and day center care plans and nursing documents.• Set up new pharmacy location and storage rooms• Created and implemented new incontinent supply delivery system to cut cost and stop diversion of supplies. Show less
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Perdiem On call Registered Nurse
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Jul 2004 - Jun 2013
Per Diem RN weekend nurse • Responsible for doing nurse visits and taking emergency on call.
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MVP Health Care
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United States
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Insurance
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700 & Above Employee
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Utilization management Care manager /Discharge Planner
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Apr 1999 - May 2005
Base Facility: Albany Medical Center Responsible for • Concurrent reviews of patient’s care at AMH • Determining levels of care, based on Interqal. • Educating MVP members and physicians on utilization of services. • Liaison for MVP member’s before, during and after hospitalization. • Arranged discharge planning needs. Base Facility: Albany Medical Center Responsible for • Concurrent reviews of patient’s care at AMH • Determining levels of care, based on Interqal. • Educating MVP members and physicians on utilization of services. • Liaison for MVP member’s before, during and after hospitalization. • Arranged discharge planning needs.
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Apria Healthcare
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Hospitality
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1 - 100 Employee
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Licensed Practical Nurse Until 1986 - Registered Nurse 1987-per deim
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Jun 1982 - Jun 2000
Licensed Practical Nurse until 1986. Registered Nurse since 1987. Staff relief at Leonard Hospital, St. Peters Hospital, Higate Manor, Albany County nursing home, Glendale nursing home Responsible for • Private duty • Pediatric and adult ventilator • Total parental nutrition cases Porta catheter( Hickman,Groshong ) Licensed Practical Nurse until 1986. Registered Nurse since 1987. Staff relief at Leonard Hospital, St. Peters Hospital, Higate Manor, Albany County nursing home, Glendale nursing home Responsible for • Private duty • Pediatric and adult ventilator • Total parental nutrition cases Porta catheter( Hickman,Groshong )
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Saint Peters Hospital
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United States
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Hospitals and Health Care
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1 - 100 Employee
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Pain Management Manager- Operating Room
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Mar 1997 - Apr 1999
Responsible for• Manager for pain management program• Ordering supplies• Monitoring patients during procedures• Prepping surgical field • Responsible for circulating and scrubbing cases• Emergency on call.• Member of the conflict resolution committee• Responsible for infection control and vaccinations for the operating room staff annually.
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Assistant Nurse Manager- Operating Room
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Jan 1992 - Mar 1997
Responsible for• Completion of scheduled and emergency cases• Schedule changes, circulating and scrubbing and administrative call• Employee evaluations and disciplinary action• Development and supervision of the terminal cleaning • Development of Operating room case cart distribution system.• Assisting with the yearly budget and data entry on A2K and Lotus123
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OB GYN Team Leader-Operating Room
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Jun 1990 - Jan 1992
Responsible for • Scrubbing, circulating and assisting anesthesia • Ordering and in servicing new equipment.• Initiated the purchase of the LEEP system and provided staff education • KTP/YAG laser certified
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Saratoga Hospital
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United States
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Hospitals and Health Care
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700 & Above Employee
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Registered Nurse Operating Room
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May 1989 - May 1990
Responsible for • Administering nursing care, controlled and directed equipment • Scrubbing and circulating, assisting anesthesia, on call responsibilities • Phlebotomy and Intravenous therapy certified Responsible for • Administering nursing care, controlled and directed equipment • Scrubbing and circulating, assisting anesthesia, on call responsibilities • Phlebotomy and Intravenous therapy certified
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RN-Patient Care Coordinator
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Aug 1988 - Jun 1989
Responsible for • Supervision of the evening shift. • Infection control chairperson, immunizations • Medication administration • Auto claving equipment • Monthly assessments of the children • Employee evaluations Responsible for • Supervision of the evening shift. • Infection control chairperson, immunizations • Medication administration • Auto claving equipment • Monthly assessments of the children • Employee evaluations
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Memorial Hospital
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Hospitals and Health Care
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700 & Above Employee
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Registered Nurse
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Jun 1987 - Aug 1988
Responsible for • In charge of a twenty eight bed unit • Ordering supplies • Administering medication • Orientation of new nurses • Patient care and family teaching • Preparing care plans • Member of the cardiac arrest team Responsible for • In charge of a twenty eight bed unit • Ordering supplies • Administering medication • Orientation of new nurses • Patient care and family teaching • Preparing care plans • Member of the cardiac arrest team
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Licensed Practical Nurse
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Jun 1987 - Oct 1987
Responsible for • Charge Nurse for thirty bed unit • Ordering and administering medications • Monthly acuity reviews of patient charts • Implementing physician orders • Employee evaluations Responsible for • Charge Nurse for thirty bed unit • Ordering and administering medications • Monthly acuity reviews of patient charts • Implementing physician orders • Employee evaluations
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Ann Lee Home
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United States
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Hospitals and Health Care
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Licensed Practical Nurse
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Oct 1985 - Oct 1986
Responsible for • Charge Nurse for thirty patients • Medication administration Responsible for • Charge Nurse for thirty patients • Medication administration
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Olsten Health Care
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United States
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Licensed Practical Nurse-perdiem
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Aug 1985 - Oct 1985
Responsible for • Staff relief in hospitals and nursing homes • Administered medication • Patient care Responsible for • Staff relief in hospitals and nursing homes • Administered medication • Patient care
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Albany Medical Center
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United States
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Hospitals and Health Care
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700 & Above Employee
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Licensed Practical Nurse
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Jul 1981 - Jul 1985
Units worked Medical Surgical, Neurology, Neurosurgery and Neurosurgery , step- down units, Orthopedic Responsible for • Patient care • Care plans • Administer medications Units worked Medical Surgical, Neurology, Neurosurgery and Neurosurgery , step- down units, Orthopedic Responsible for • Patient care • Care plans • Administer medications
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Mental Hygiene Therapy Aide-Autism
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Jun 1980 - Jun 1981
Responsible for • Teaching Autistic clients activities of daily living and behavior modification • Supervision of clients Responsible for • Teaching Autistic clients activities of daily living and behavior modification • Supervision of clients
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Education
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2014 - 2014
IPRO
Certification, Screen Training -
2012 - 2013
Health Commerce NYS
Certification, Uniform Assessment Service -
2007 - 2013
Northeast Health
Certificate, Lean Training -
2008 - 2008
ITC
Certificate, Pro-time training -
2005 - 2007
Northeast Health
Silver Certificate, Management Development -
2006 - 2006
Northeast Health
certificate, Reasonable Suspicion -
2004 - 2004
IPRO
certification, Patient Review Instrument -
1998 - 2001
Concordia College
Bachelors of Science, Nursing -
1989 - 1989
Saratoga Hospital
Certificate, Perioperative/Operating Room and Surgical Nurse/Nursing -
1985 - 1987
Maria College of Albany
Associate of Arts and Sciences (AAS), Nursing -
1979 - 1981
Albany BOCES-Adult Practical Nursing Program
Practical Nursing diploma, Practical Nursing -
1976 - 1980
Linton High School
Diploma, Regents
Community
