Director of Medical Management Ambetter/Allwell

• Jul 2019 - Present

Senior Trainer Auditor/ Registered nurse

• Aug 2017 - Jul 2019

Develop and conduct clinical education courses, including case management education and training for new employees.Develop and maintain complex audit processes and audit tools related to authorizations, appeals, quality, case management, inter-rater reliability and data entry. Audit established guidelines for medical necessity. Analyze training needs and identify, select or develop appropriate training programs including training aids and materials. Audit staff in accordance with established auditing processes, work with staff to identify and resolve errors in data and reporting, and present findings and recommendations for improvement to management. Train audit staff in the use of audit tools and identification of patterns or trends that require additional training or corrective action. Evaluate effectiveness of training programs including cost/benefit analysesResearch, analyze, and recommend internal/external training programs. Maintain records of training activities and employee progress Assist with revisions to Policy and Procedure and/or work process development.

Case Management Nurse

• Feb 2014 - Jul 2017

Develop, assess and adjust, as necessary, the care plan and promote desired outcome.Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options.Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients.Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs.Provide patient and provider education.Facilitate member access to community based services.Monitor referrals made to community based organizations, medical care and other services to support the members’ overall care management plan.Actively participate in integrated team care management rounds.

Branch Manager

• Mar 2012 - Feb 2014

Responsible for the administration of the day-to-day operations of the home care facility. This includes: coordinating and completing assigned projects to effectively support the immediate and long range objectives of the company; oversight of the eligibility of patients referred to home care services, planning for the services to be provided to patients and supervising their total home health care; implementing and maintaining administrative practices, agency goals, and policies which assure compliance with applicable state and federal regulations; enhancing the profitability of the agency; and providing motivation and retention of a qualified staff and assure the quality of services delivered. I also acted as a liaison with management staff, medical directors and other departments throughout the company.