Elaine Rousseau Email & Phone Number

Needham,Ma.

Watertown, Ma.

• Ensured completion of quarterly clinical compliance audit results and oversight of associated corrective action plans for approximately 200 cases per quarter• Researched, developed and corrected clinical department policies procedures and workflows to ensure adherence with all state and federal regulations• Enhanced knowledge of CMS regulations participating in CMS site visits, development of universes, assessment of areas at risk, and presenting case reviews to auditors• Managed project and auditing of CMS Part C/D reporting initiatives leading the clinical audits and reporting of data of approximately 2000 cases per quarter

Watertown, Ma.

• Provided guidance and oversight to a clinical case management staff of 13 Case managers and their assigned medical groups assuring effective utilization review and discharge planning through the application of Interqual, and CMS coverage criteria• Improved Case Management training programs, developed new materials and provided training for new case managers, physicians and office staff with excellent evaluation scores• Communicated and incorporated expert knowledge of Medicare regulations and guidelines into day to day clinical operations and workflows followed by auditing of clinical records to assess effectiveness• Reviewed 300 medical records annually for appeals and grievances, fast track appeals, acting as a clinical consultant providing medical record assessments and recommended corrective action steps

• Oversight of the delegated network both Commercial and Senior Products, with corporate recognition for project work that added 20,000 new Medicare members to managed care plan• Developed Case Management training program and implemented program for new delegated case managers and new delegation nurse consultants

Worcester, Ma.

• Developed workflows and managed appeals ensuring compliance with CMS regulatory standards• Managed caseload of 50-60 Senior and Commercial members ensuring provision of quality care within the member’s benefits• Developed case management department policies and procedures assuring compliance with NCQA & CMS standards

Millbury, Ma.

• Managed the operation of 138 bed long-term care facility employing 120 clinical staff. • Prepared and obtained first JCAHO certification for the facility

Ms, Nursing Administration

Activities and Societies: Sigma Theta Tau Nursing Honor Society

Bsn, Nursing

Activities and Societies: Sigma Theta Tau Nursing Honor Society