• Completes bi-weekly interdisciplinary team (IDT) assessments with home health agencies on BPCIA (Bundle Payment Care Improvement Advance) high and medium risks patients to confirm active status and services rendered for 90 days to reduce risk of readmissions.• Contacts primary care physicians and specialists to confirm post hospital appointments were scheduled. • Participates in weekly BPCIA case reviews with director and transition of care team to discuss barriers, recommendations and process and performance improvements. • Conducts psychosocial assessments on Next Gen patients who were discharged from home health and skilled nursing facilities to identify any Social Determinants of Health (SDOH) such as unsafe home environment, transportation, financial or prescriptions needs to refer to appropriate local, federal, and state community services. • Works in collaboration with patients, caregivers, and primary care givers to arrange home health needs when identified. • Provides supportive counseling to patients, caregivers, and family members. • Maintains knowledge of community resources within the local and regional areas

• Outreached to home health providers to identify continued skilled need and request current home health 485 for review to make appropriate recommendations to the primary care physician. • Participated in weekly case review meetings to discuss patients with high utilization of home health services, identify barriers and make recommendations to facilitate an appropriate discharge.• Referred patients to home health social worker to assess psychosocial, community resource and long-term planning needs

• Supervised the daily productivity, training, development, and work assignments of the Medical Management team. • Worked closely with Department Director to identify and plan for opportunities of performance improvements to enhance the case management enrollment process to maintain operational efficiency. • Successfully increased enrollment and reduced ED visits and readmission by 20%.• Ensured appropriate application of the current evidence-based criteria within the utilization review process by conducting monthly audits to monitor performance standards with the goal to achieve 90% and above accuracy. • Participated in reports of quality of care, case reviews, and provided information regarding utilization requirements and operational procedures to members, providers, and facilities. • Worked collaboratively with the Quality team to achieve NCQA accreditation for the case management department. • Performed monthly audits on case management files to ensure quality and accuracy aligned with NCQA accreditation and other regulatory requirements.• Ensured the staff remained within 80-100% compliance with NCQA/URAC, state and federal guidelines. • Participated in workgroups and committees oriented toward improving health plan standard of operations, such as policy and procedure committee and NCQA workgroup. • Performed utilization review on inpatient admissions, outpatient surgeries, transplant services, dialysis, and NCI clinical trials to ensure turnarounds times were met within 2 days at 90% and 3 days at 100% accuracy.• Educated members on their disease processes to reduce ED visits and hospitalizations to achieve an optimal outcome. • Developed and maintained policies, procedures, and workflow desktops for the department. • Expert knowledge of Medicare, Medicare Advantage, Health Exchange, Social Security Disability, Supplemental Security Income, Retired Military and Managed Medicaid health plans.

• Managed team of 13 staff members and the day-to-day activities of the Utilization Management Department. • Collaborated with the utilization management staff and medical director to facilitate appropriate treatment throughout the healthcare continuum of care.• Conducted weekly care review meetings with concurrent review staff and case managers with the focus of reducing hospital length of stays by transitioning patients to the appropriate level of care. Successfully reduced length of stays by 25-30%.• Supported the operational development, implementation and ongoing performance improvement and effectiveness in collaboration with the utilization management clinical programs and health plan business units.

• Performed telephonic case management outreach calls to geriatric and high-risk populations to enroll into complex case management and disease management. • Assessed, planned, implemented, monitored, and evaluated options to meet the members healthcare needs. Resulted in achieving a high level of member satisfaction.• Collaborated with physicians and facility multidisciplinary team members to develop a plan of care for each patient to ensure progression toward desired outcomes. • Collaborated with facility multidisciplinary team to coordinate target length of stay and an optimal transition to the appropriate level of care. • Initiated post-acute discharge calls to ensure the identified members have transitioned to the appropriate level of care with all ordered services such as home health, DME, medications and follow up MD appointments and to resolve any post discharge barriers.

Managed daily operations and plans for all pre-admission activities. Coordinated the multidisciplinary team meeting for the patient's discharge needs. Performed utilization review to ensure appropriateness of admission by applying InterQual Criteria. Provided initial and continued stay reviews to insurance companies to obtain authorizations.

• Coordinated the plan of care from admission to discharge in collaboration with the medical director and rehabilitation team.• Implemented discharge planning to identify and address the patient’s psychosocial needs and support systems.• Conducted daily rounds and communicated with patients to ensure they were meeting their rehab goals.• Daily meetings with the Physical, Occupational and Speech Therapists to identify discharge barriers and establish effective resolutions.• Coordinated the weekly bedside team conference, plan of care and family training, improving patient care.• Educated the patients and families on appropriate community resources to ensure a safe discharge. • Performed ongoing utilization review for Medicare to comply with all guidelines and regulations. • Provided concurrent reviews to commercial insurers to ensure quality of care and cost-effective treatment during the rehabilitation admission.• Completed chart audits to ensure compliance with JCAHO standards.

• Coordinated the plan of care from admission to discharge in collaboration with the medical director and rehabilitation team.• Implemented discharge planning to identify and address the patient’s psychosocial needs and support systems.• Conducted daily rounds and communicated with patients to ensure they were meeting their rehab goals.• Daily meetings with the Physical, Occupational and Speech Therapists to identify discharge barriers and establish effective resolutions.• Coordinated the weekly bedside team conference, plan of care and family training, improving patient care.• Educated the patients and families on appropriate community resources to ensure a safe discharge. • Performed ongoing utilization review for Medicare to comply with all guidelines and regulations. • Provided concurrent reviews to commercial insurers to ensure quality of care and cost-effective treatment during the rehabilitation admission.• Completed chart audits to ensure compliance with JCAHO standards.