Evette Ashby Email & Phone Number

Texas, United States

Killeen/Temple, Texas Area

- Provided key leadership in the successful restructuring and process improvements of the Utilization Review department resulting in CMS post-audit validation success, successful NCQA accreditation, TDI Triennial audit, and recognition as one of the 2019 Best Insurance Companies for Medicare Advantage by U.S. News & World Report - Guided Senior Management on identifying problem areas, formulating solutions and implementing actions to ensure compliance. Developed, implemented and maintained policies & procedures to improve UM operations. - Improved team productivity and compliance while simultaneously reducing staff 30%.Currently maintaining effective oversight of utilization management for a +200k member plan.

Killeen/Temple, Texas Area

-Supported preparation for CMS and (other auditor) site visits and audits, including creation of policy and -procedure documents, process maps and other collateral required by reviewer. -Scheduled, provided daily assignments, and coached a team of 16+ direct reports.-Supervised team to ensure the following:-Completion utilization management and concurrent review -Determination of medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines. +Management the utilization of Contracted, DME and HH, and outpatient approvals and denials +Assessment, interpretation, and response to customer needs or requirements +Identification of solutions to non-standard requests and problems +Determination of medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines (InterQual, SWHP Medical Policy, CMS criteria, etc.) and benefit determination. +participation in process improvement projects to continuously enrich care coordination efforts and ensure evidenced based processes were utilized.

Central Texas

- Developed and delivered employee training to meet regulatory standards andbusiness objectives - Analyzed audits and performance metrics to identify trainingopportunities - Created documentation of processes and best practices - Supervised UM nurses per business demands

Austin, Texas Area

Austin, Texas Area

-Assesses, plans, implements and coordinates case management activities with members and providers-Evaluates the medical and benefit needs of the member -Facilitates the member’s overall wellness and timely return to work-Develops a proactive course of action to address issues and enhance outcomes -Develops, implements and supports health strategies, policies and programs-Ensures the appropriate delivery of benefits-Assess the need for a referral to clinical resources for assistance-Utilizes case management processes in compliance with regulatory and company policies and procedure-Member Advocate

-Assesses, plans, implements and coordinates case management activities with members -Evaluates the medical and disability needs of the member -Facilitates the member’s overall wellness and timely return to work-Develops a proactive course of action to address issues and enhance outcomes -Develops, implements and supports health strategies, policies and programs- Ensures the appropriate delivery of benefits-Assess the need for a referral to clinical resources for assistance-Presents cases at case conferences for multidisciplinary focus to benefit overall claim management-Utilizes case management processes in compliance with regulatory and company policies and procedure

Charlottesville, Virginia

-Responsible for assessment, care and well-beingof labor and delivery, postpartum and well nursery patients-Provided staff education on Fetal Monitoring

Charlottesville, Virginia

-Responsible for assessment, care and well-beingof labor and delivery and postpartum patients-Presented Prenatal Education Series, February- March 2004

Virginia Beach, Va

-Responsible for staffing, provided patient care in postpartum,well nursery and medical surgical oncology.-Served as Planner and Instructional Assistant for Computerized Charting InitiativeProvided instruction and maintained role of "superuser" for the year of initiating CCI.January 2003-January 2004

Roanoke, Virginia

-Internship in Obstetrical Gynecological Nursing

Bachelor Of Science Of Nursing, Nursing

Dean's List Fall 2004

Associates Of Science Of Nursing, Nursing

CurricuIum Committee/Student Representative Assisted in the development and curriculum review of Associate in Nursing Program 2001-2002.

Education record