Monica Dantzler-Thomas, Rn, Msn, Mha, Ccm, Lnc Email & Phone Number

Columbia, MD, US

Washington D.C. Metro Area

• Responsible for overall operations and oversight of forty-nine Care Management Accreditations.
• Serves as the primary contact for accreditation-related questions and requests from clients.
• Assists and advises clients and prospective clients through application processes.
• Oversees and manages accreditation-related tasks.
• Assists with development of program standards.
• Monitors accreditation trends and identifies issues.

• Review and abstract medical data from medical records
• Review assigned medical records in order to abstract specified and required clinical data elements to determine provider performance on specific quality measures.
• Perform telecommute medical record abstraction
• Comply with appropriate procedures for reviewing records remotely
• Document abstraction findings as required and prepare additional reports as needed
• Communicate all project issues including scheduling… Show more

Arlington, VA

• Provide direction and oversight of the Centers for Medicare and Medicaid Services (CMS) Center for Program Integrity RAC Validation Contract
• Responsible for overall operations for Medical Review.
• Compile program management reports, action item collection and monitoring of deliverable submission
• Develop standard tracking and reporting tools for effective program management, and a variety of special projects.
• Document and track team deliverable in program management tools… Show more
• Document and track team deliverable in program management tools

Washington D.C. Metro Area

• Provide direction and oversight of all Utilization Management functions, ensuring the activities are aligned with the mission and vision of the organization
• Responsible for overall operations for Medical Review
• Increase the likelihood of hospital cost reimbursement for patient treatment through insurance by ensure patients fit the medically necessary criteria to be admitted.
• Recouped over 1 million dollars in denied claims over a 3-month period
• Provide statistics and… Show more
• Provide statistics and trend reports for all utilization processes

Rockville, Maryland

• Provided direction and oversight of the Centers for Medicare and Medicaid Services (CMS) Medical Review Task under the Payment Error Rate Measurement (PERM) post payment review contract
• Increased the amount of medical services allowable for reimbursement under federal government funding by performing documentation reviews, scrutinizing all billing and medical documentation for correct medical codes.
• Responsible for overall operations for Medical Review
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• Performed 500 reviews weekly with a 98%accuracy
• Developed, implemented and maintained compliance, policies and procedures regarding medical review functions. Show less

Washington D.C. Metro Area

• Provided administrative and clinical supervision in the Case Management Department that supported the Federal Employee Program (FEP) and Patient Centered Medical Home (PCMH)
• Acted as point of contact and subject matter expert regarding the FEP Medical Case Management Services
• Incorporated principles of managed care and utilization management into case management policies and procedures to ensure the timely flow of case management activities meet program goals and objectives
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• Assisted with departmental preparation for the URAC/NCQA Accreditation
• Performed weekly productivity reviews, case audits and documentation requirements to ensure program compliance

• Trained, managed, supervised and evaluated 12 Registered Nurses.
• Led the daily operations of the outpatient and inpatient preauthorization units for the delivery of medical review services.
• Increased claim review volume by 60% and stabilized core staff, within the first 4-6 months of employment
• Cleared backlog of 700 cases, within a 3-month timespan of employment
• Participated in the development of processes, systems, and practice metrics; developed department policies… Show more
• Participated in the development of processes, systems, and practice metrics; developed department policies, procedures and workflow

Columbia, Maryland

• Provided technical assistance to Center for Medicare and Medicaid Center for Program Integrity Division of Plan Oversight and Accountability and Division of Policy and Regulatory Development oversight strategy to.
• Served as a Subject Matter Expert (SME) concerning Medicare Part C and Medicare Part D.
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• Provided overall national program support for and analysis of Medicare Part C and D program integrity initiatives by focusing on process, operational risks, and program vulnerabilities.
• Developed, reviewed and analyzed reports to communicate recommendations for audit methodology, system vulnerabilities, and program vulnerabilities. Due to recommendations, $4 million recovered Show less

Washington, DC

• Responsible for utilization of on-site reviews of adults with commercial insurance
• Consulted with the Medical Director for medical necessity determinations and appropriateness of
• Serve as a liaison for discharge planning needs between organization Case Managers and the community such as Home Health, Acute Rehab, and Durable Medical Equipment (DME), to support optimal functioning.

• Developed and implemented a Case Management and Quality Management program for a Managed Medicaid Patient Centered Medical Home startup.
• Responsible for overall operations for Case Management and Quality Management
• Reviewed analyzes of activities, costs, operations and forecast data to determine progress toward stated goals and statistical/financial purposes
• Promoted compliance with federal and state regulations and contractual agreements
• Developed and… Show more
• Developed and implemented Disease Management Program for Asthma, Diabetes, Hypertension and Maternal Health

Masters Of Science In Nursing/ Masters Of Science In Healthcare Administration, Nursing, Healthcare

Activities and Societies: Sigma Theta Tau International, Inc.

Diploma, Legal Nurse Consulting

Bachelor Science In Nursing, Nursing

Activities and Societies: Delta Sigma Theta Sorority, Inc Chi Eta Phi Sorority, Inc Health Professionals

Education record