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HEALTHCARE: CASE MANAGEMENT
Highly qualified and patient-focused executive management leader with rich experience in case management, resource management, patient care, instructing, program planning, treatment scheduling/planning and operations management. Goal-oriented, calm, patient and dedicated professional, with 10+ years of rich experience in case management, utilization review, administrative management, patient care, program development, support, quality and compliance. Combines strong leadership skills and management skills with medical support as an inspirational team leader with a proven proficiency in patient care operations and administrative management.
• Polished communicator, adept at spearheading interaction among multiple clients including physicians, nurses, patients, families, and others.
• Pragmatic, goal-oriented advocate, with distinguished career supporting medical assistance strategic and project leadership.
• Quantifiable achievement and a proven record in case management, resource management and delivering exceptional patient care.
• Reputed as expert presenter, instructor, negotiator, and businessperson able to forge solid relationships with strategic partners and build consensus across various organizational levels.
• Savvy, resourceful leader demanding and delivering the highest standards of professional excellence in compliance, and resource management.
Case Management • Utilization Review • Plan Development • Condition Code 44 • Operations Management • Patient Relations • Healthcare Services • Business Development • Program Development Recruitment & Training • Budgeting • Medical Instruction • Medical Assistance • Patient Care Placement Team Leadership • Operations Improvement • Communications • Program Management
HCA, Regional Medical Center, San Jose • CA
Assistant Director Case and Resource Management 2010 – Present
Successfully managed operations and 20 case managers, social workers, and support personnel. Monitored daily operations and made adjustments as needed. Facilitated with managerial support to front line staff. Accountable for the daily management of insured patients to ensure clinical reviews are being completed. Effectively interacted with physicians to facilitate placement of patients in the appropriate level of care. Supervised one day and two day stays both concurrently and retrospectively to ensure that billing aligns with medical necessity. Adhered to compliance with state, federal, and local laws pertaining to healthcare.
• Proficiently integrated and evaluated the implementation of the MIDAS case management software package.
• Oriented new case managers to using Interqual Criteria to ensure appropriate utilization of hospital resources.
Utilization Review/Case Management 2006 – 2010
Efficiently conducted internal audits of utilization review and case management objectives. Conducted Medicare audits and case management for hospitalized clients. Arranged follow-up care for discharged clients.
• Evaluated Medical denials for appeals and followed up on billing issues related to insurance.
• Skilled at using case management software, navigate Medical web services and use Interqual and Millman criteria for utilization review.
Mission College, Santa Clara • CA 1997 – Present
St. Francis Career College, San Jose • CA 2004 – 2006
Innovatively developed course objectives and class lectures. Produced and selected appropriate course materials. Developed written evaluation instruments. Evaluated student understanding and application of didactic instruction by direct observation in a clinical setting.
• Integrated theoretical and clinical nursing experience.
• Remediated students as needed and possessed all clinical nursing skills required in an acute care psychiatric setting and an acute care medical setting.
Gardner Family Health Network, San Jose • CA 1997 – 2004
Homeless and Offsite Program Coordinator – Psychiatric Program
Advised clinical and non-clinical staff on the provision of quality nursing care. Consulted with support staff to ensure the timely administration of medical services. Designated the scope of services rendered by the program. Scheduled and coordinated clinical services at multiple locations throughout Santa Clara County. Provided staff development to program personnel. Evaluated program for compliance with state and federal mandates. Monitored compliance with contracts, designed and implemented plans for a mobile medical unit.
• Coordinated services provided by Healthcare for the Homeless.
• Conceptualized and implemented written policies and procedures.
• Monitored program budget and familiar with Title 16 and Title 22.
Prior 1997: Worked as a Charge Nurse, Emergency Department at Kaiser Hospital, Santa Clara • CA
EDUCATION, CREDENTIALS AND LICENSURE
EdD, Organizational Leadership – in progress
Walden University, Argosy University
MSN, Nursing Education
San Jose State University, San Jose • CA
Evergreen Valley College, San Jose • CA
State of California Public Health Nursing License • # 50388
State of California Registered Nursing License • # 457647