Clinical Delegation Oversight

Accountable to deliver clinical quality tools and capabilities that enable the delivery of products and services to fully meet the expectations of our customers at all times. Enhance individual clinical staff effectiveness, to increase customer focus, improve operating discipline, and reinforce value creation.Supports activities necessary for ongoing management of centralized audit to over 4,000 clinical staff members.Responsible for completing clinical case and call audits identified through random sampling. Complete and timely documentation of audits serve as communications to operations highlighting successes and areas of opportunity for nurse case management coaching events. Ensure all audits meet accreditation, customer and internal process requirements/deadlines.Review process activities and address areas for improvement within centralized auditing and operations.Respond to questions regarding auditor feedback and provide guidance/training within operations to ensure accurate audit compliance.

RN that identifies, coordinates, and provides appropriate levels of care through various stages in pregnancy for low and high risk members. Responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, medical management consulting and providing health education/coaching. * Making outbound calls to assess members' current health status * Identifying gaps or barriers in treatment plans * Providing patient education * Interacting with Medical Directors on challenging cases * Coordinating care for members * Making referrals to outside sources * Coordinating services as needed (home health, DME, etc) * Encouraging members to make healthy lifestyle changes * Documenting and tracking findings * Making post-discharge calls to ensure that discharged member receive the necessary services and resources - Assesses and interprets customer needs and requirements.- Identifies solutions to non-standard requests and problems.- Solves moderately complex problems and/or conducts moderately complex analyses.- Works with minimal guidance; seeks guidance on only the most complex tasks.- Translates concepts into practice.- Provides explanations and information to others on difficult issues.- Coaches, provides feedback, and guides others.- Acts as a resource for others with less experience.

•Individualized nursing care of routine post partum, cesarean section and newborn patients.•Worked as a team leader in the newborn nursery handling emergency situations and involving appropriate departments and resources in managing unstable newborns after birth.•Excellent organizational and time management skills as reflected in meeting discharge time frames.•Delivered excellent customer service to all matrix partners.•Seen as a knowledge resource to both superiors and peers regarding the computer training for new electronic documentation system and eagerly shares knowledge with peers in order to build a strong and dynamic work environment.•Participated in various quality initiatives including the Pain Management Committee, chart audits for JCAHO and employee satisfaction.

•After hour authorizations of inpatient/outpatient services for both medical and behavioral health UM.•Documented accurate CPT-4, ICD-9 and HCPCS coding to facilitate accurate data capturing and reporting.•Front line intake for triage calls and crisis calls, after hours.•Delivered excellent customer service to all matrix partners•Seen as a knowledge resource to both superiors and peers regarding the various health plans and eagerly shares knowledge with peers in order to build a strong and dynamic work environment.

•Managed medical referrals and authorizations of inpatient/outpatient services.•Documented accurate CPT-4, ICD-9 and HCPCS coding to facilitate accurate data capturing and reporting.•Assisted providers/facilities with inquiries regarding contracts, claims, appeal status, fee schedules, prior authorization guidelines policies/procedures and other various issues.•Delivered excellent customer service to all matrix partners

•Assured accuracy of all correspondence and reports.•Managed multiple tasks and heavy workloads in a pressured environment.•Maintained the scheduling, support and time management for 5 Medical Directors, Health Services Director and department managers. •Communicated with internal and external customers in a clear and concise manner. •Lead for departmental Y2K rollout and responsible for scheduling all training for local and offsite UM offices in Tampa, Orlando and South Florida.

•Aided in all administration duties including projects, document distribution, queue lines and entry/retrieval of medical data in an accurate and timely manner.•Requested statistical data/reports from Information Systems for any trending or reporting needs of the management and aided in the completion of periodic inpatient and outpatient precertification summary reports and phone statistic reporting.