Heidi Egeberg Email & Phone Number

Saint Paul, Mn, Us

Teleworker - Woodbury, Mn

Lead the National Precertification List (NPL) process and program management - Scorable Action Item (SAI) ideation - Development - Impact scoring - NPL Committee facilitator - Implementation - Internal and external communications - Policy Support - Return on investment (ROI) process and annual reviewSite of Service Outpatient Surgery Program subject matter expertPrecertification SAI project management

Saint Paul, Minnesota

I manage a clinical team that reviews both Commercial and Medicare plans. We specialize in review of complex spinal surgery, designated precertification plans, higher benefit level/network deficiency reviews, predetermination (courtesy reviews), oral maxillofacial surgery, gender affirming surgery, urgent/expedited/state mandated turn around time precertification requests, special case precertification requests (i.e., out of country admissions, hemophilia, etc...) and private duty nursing. I also offer oversight to our offshore vendor partners.

Teleworker

Develop and implement strategy for policy/program development that considers all involved areas (e.g., systems, actuarial, marketing, etc.) and the potential impact on all managed care productsOperationalize strategy - Prioritize projects - Design programs and develop policies - Identify and involve appropriate subject matter experts (those who will operationalize programs) - Design/manage implementation including business processes, system and other modifications - Design and manage communications and trainingAnalyze ongoing performance data and utilize to initiate/ implement changesSelect, build and manage strong teams through training, diverse assignments, coaching/ mentoring and performance managementNegotiate and manage contractual arrangements Serve as a technical business resourceManage business relations with I/T organization

Teleworker

- Oversees the implementation of Aetna medical management services and monitors daily performance to ensure business goals are met and compliance with Aetna policies and procedures is maintained - Implements clinical policies & procedures in accordance with NCQA, URAC, state and federal standards and mandates - Serve as a content model expert and mentor to the team regarding practice standards, quality of interventions, problem resolution and critical thinking - Ensure implementation and monitoring of best practice approaches and innovations to better address the member's needs across the continuum of care - Develop/assist in development and/review new training content- Collaborate/deliver inter and intra-departmental training sessions - Protects the confidentiality of member information and adheres to company policies regarding confidentiality - Manages resources responsible for identification of members, development and implementation of care plans, enhancement of medical appropriateness and quality of care and monitoring, evaluating and documenting of care - Communicates productivity expectations, balance workload, monitor efficiency and initiate control measures to minimize variances in workload over time - Ensures the team's understanding and use of information system capability and functionality (*)- Select staff using clearly defined requirements in terms of education, experience, technical and performance skills - Assesses developmental needs and collaborates with others to identify and implement action plans that support the development of high performing teams - Articulate performance expectations and team objectives while collecting and interpreting balanced measure to evaluate individual staff and team performance - Lead change efforts while managing transitions within a team - Create a positive work environment by acknowledging team contributions, soliciting input, and offering personal assistance, when needed

Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations. Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. Data gathering requires navigation through multiple system applications. Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.Condenses complex information into a clear and precise clinical picture while working independently.Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated.

Bachelor Of Science (B.S.), Registered Nursing/Registered Nurse

Activities and Societies: Epsilon Sigma Kappa Rho Honor Society North Dakota Student Nurse Association - State Legislative Education Officer

Registered Nursing/Registered Nurse