Donna Pandolfi Email and Phone Number

RN Case Manager - Workers’ Compensation Department :• Assess current medical status and future medical management needs of injured worker• Analyze and integrate complex medical information in terms of clinical findings, diagnostic studies, treatment plan• Identify treatment inconsistencies that do not meet established guidelines for Standard of Care • Coordinate and facilitate medically appropriate services• Identify and coordinate use of internal and external resources•… Show more RN Case Manager - Workers’ Compensation Department :• Assess current medical status and future medical management needs of injured worker• Analyze and integrate complex medical information in terms of clinical findings, diagnostic studies, treatment plan• Identify treatment inconsistencies that do not meet established guidelines for Standard of Care • Coordinate and facilitate medically appropriate services• Identify and coordinate use of internal and external resources• Collaborate with medical provider and employer to expedite early return to workRN Case Manager - Stop Loss Department:• Established the Stop Loss Clinical Consultant position• Developed written guidelines and workflow procedures • Established collaborative relationships with Third Party Administrators and Case Managers to co-manage high risk / catastrophic cases and pursue cost-effective alternatives• Developed vendor network • Identify, coordinate and actively pursue all areas of opportunity for cost savings• Support underwriting department by projecting medical costs through assessment and interpretation of medical / financial information• Support claim department by reviewing files for appropriateness of charges and cost savings while ensuring treatment and services provided meet policy definition• Comprehensive review of all pre-claim and catastrophic notices • Timely involvement on cases identified for intervention with a strong emphasis on proactive management to minimize financial risk• Key contributor to Stop Loss Policy Re-write• Actively participate in educational initiatives focused on quality of care and cost containment Show less

• Clinical resource for claim, underwriting, legal and sales unit• Clinical contact for Third Party Administrators and vendors• Coordinated and facilitated physician peer review and referral to value-added vendors• Managed cases identified for intervention and pursued cost-effective initiatives for positive savings outcome• Identified and researched investigational and experimental treatment based on established Standards of Care, Compendium, NCCN, FDA and policy… Show more • Clinical resource for claim, underwriting, legal and sales unit• Clinical contact for Third Party Administrators and vendors• Coordinated and facilitated physician peer review and referral to value-added vendors• Managed cases identified for intervention and pursued cost-effective initiatives for positive savings outcome• Identified and researched investigational and experimental treatment based on established Standards of Care, Compendium, NCCN, FDA and policy language• Reviewed claim files for medical appropriateness according to plan documents and standard of care• Collaborated with underwriting unit in analyzing data and evaluating financial impact of disease process • Identified Third Party Administrator issues and worked toward positive resolution • Developed training process for Case Management Assistant• Valuable contributor to the Genworth / Sun Life Financial integration process Show less

• Supported underwriting unit in evaluating financial risk for potentially catastrophic claims • Oversaw case management performed by Third Party Administrators and vendors• Reviewed claim files for appropriateness of treatment in accordance with plan documents, Standards of Care• Coordinated and facilitated physician peer review and referral to value-added vendors

• Conducted comprehensive clinical assessments of long term disability claims• Evaluated medical findings as they related to functionality• Collaborated with health care providers and employers to establish work readiness and facilitated return to work opportunities• Provided on-going case management services to facilitate optimum claim resolution• Identified and coordinated independent medical evaluations, peer consultations, and on-site evaluations• Actively participated… Show more • Conducted comprehensive clinical assessments of long term disability claims• Evaluated medical findings as they related to functionality• Collaborated with health care providers and employers to establish work readiness and facilitated return to work opportunities• Provided on-going case management services to facilitate optimum claim resolution• Identified and coordinated independent medical evaluations, peer consultations, and on-site evaluations• Actively participated in department / team initiatives to establish action steps consistent with claim management strategies• Served as medical information resource and mentor Show less

• Coordinated and ensured high quality, cost-effective health services for the Medicare population • Identified and implemented appropriate health care alternatives within Medicare guidelines• Designated Case Manager responsible for Diabetic Disease Management Program• Resource to in-house personnel regarding medical questions and determinations• Maintained direct relationship with Provider Health Organization• Member and active participant in Medicare Operations Work Group… Show more • Coordinated and ensured high quality, cost-effective health services for the Medicare population • Identified and implemented appropriate health care alternatives within Medicare guidelines• Designated Case Manager responsible for Diabetic Disease Management Program• Resource to in-house personnel regarding medical questions and determinations• Maintained direct relationship with Provider Health Organization• Member and active participant in Medicare Operations Work Group and the Network Contracting Committee Show less

• Responsible for case management, utilization review, and authorizing home care services for 25,000 covered lives in a Medicare risk capitated contract• Developed and implemented product lines including Outcome Standards and Disease Management programs• Provided education and training to the staff of 14 agencies within the VNA Managed Care network• Liaison at weekly grand round meetings with health care industry representatives in order to effectively manage high-risk clients… Show more • Responsible for case management, utilization review, and authorizing home care services for 25,000 covered lives in a Medicare risk capitated contract• Developed and implemented product lines including Outcome Standards and Disease Management programs• Provided education and training to the staff of 14 agencies within the VNA Managed Care network• Liaison at weekly grand round meetings with health care industry representatives in order to effectively manage high-risk clients across the entire continuum• Member and active participant in Clinical Standards Committee• Active in marketing strategies and presentations Show less

• Collaborated with insurance plan and health care clinicians to facilitate and coordinate home care services• Assessed patient status/plan of care and evaluated medical necessity of requested services• Secured insurance company authorizations for medically appropriate services• Tracked and billed services via FOS

• Managed, coordinated and assessed the care of clients with catastrophic illnesses and injuries• Primary specialty in home care, intravenous therapy, rehabilitation and medical/surgical• Counseled clients and families on appropriate treatment alternatives and use of financial resources• Effectively negotiated with providers and conducted national pilot for retrospective negotiations• Developed case management practice protocols• Networked and coordinated educational… Show more • Managed, coordinated and assessed the care of clients with catastrophic illnesses and injuries• Primary specialty in home care, intravenous therapy, rehabilitation and medical/surgical• Counseled clients and families on appropriate treatment alternatives and use of financial resources• Effectively negotiated with providers and conducted national pilot for retrospective negotiations• Developed case management practice protocols• Networked and coordinated educational in-services Show less

• Responsible for concurrent and prospective telephonic utilization review for medical necessity using general medical practice standards• Coordinated and implemented cost-effective services within benefit plan provisions• Piloted and implemented chiropractic review

• Liaison between disabled clients and insurance companies• Recommended and implemented cost-effective health care management• Vocational counselor responsible for clients’ timely return to appropriate employment• Marketing specialist actively promoted cost-containment services• Conducted hospital bill audits

• Charge nurse responsible or 54-bed medical, surgical, orthopedic specialty unit• Provided direct patient care