Experience

Anthem

• United States
• Insurance
• 700 & Above Employee

• Manager II

  • Apr 2010 - Present

  Responsible for managing a team of nurses and NCS charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources within Acute, PA, and Initial SNF. Primary duties include: Ensuring adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Areas managed include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Management responsibilities include hiring, training, coaching, counseling, and evaluating performance of direct reports. Further management duties include development of programs and initiatives with core team members from all areas to address quality and improvement needs for the business unit as a whole.



Anthem, Inc.

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Manager II

  • Nov 2008 - Present

  Responsible for managing a team of nurses and non-clinical associates charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources within Acute, PA, and Initial SNF. Primary duties include: Ensuring adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Areas managed include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Management responsibilities include hiring, training, coaching, counseling, and evaluating performance of direct reports. Further management duties include development of programs and initiatives with core team members from all areas to address quality and improvement needs for the business unit as a whole.



Wellpoint/Sr. Specialty Case Management Program

• Senior Case Manager

  • Nov 2008 - Present

  Nurse Case Manager Senior I for the Sr. Specialty Case Management Program/CKD/ESRD. Responsible for managing the needs of members with CKD/ESRD. Education and facilitation regarding co-morbidities and current health status. Providing service that is medically appropriate, high quality, and cost effective while ensuring adherence to medical policy and member benefits. Consulting with physicians and ancillary personnel, facilitating treatment plans and managing disease states to affect outcomes. Responsible for identifying measurable process improvements and facilitating improvement for the team, to include integration of the discharge planner piece which has shown increased cost savings and increased benefit to members. This included managing of members noting medically appropriate, high quality, and cost effective services. Developed the Discharge Planning Program to incorporate Care Transitions. This included following members through the discharge process to affect re-admissions, collaboration with providers and steering members to appropriate providers, programs or community resources.