Sandra D. Email & Phone Number

Remote

Performs in a pre service role as a clinical gatherer and authorization document creator. Perform clinical and authorizations for all prospective, concurrent, and retrospective requests within established parameters for LTAC or IRF.Performs review for all direct admissions. Performs all Expedited prospective reviews, including the patient oral and/or written notificationsPerforms all Standard prospective reviews, including the patient oral and/or written notifications.Coordinates Medical Director reviews for PAC. Coordinators peer to peer reviews with naviHeealth - UHG Medical Directors.Notifies hospital and requestor with review outcomes. Completes processes as it relates to pre-service authorizations for post acute care. Educates facilities on pre-service denial process.Navihealth merged with UHC Optum. Optum division is now known as Home and Community Care.Other performing position as a Continued stay review coordinator.

Clinical Quality Analyst Performs, analyzes, updates, and modifies assigned procedures and processes to continually improve QI operations.Pursues methods to ensure receipt of valid data required for trending and reporting of various QI work plan metrics.Collects and summarizes performance data, performs adequate data/barrier analysis, identifies opportunities for improvement, develops improvement recommendations, presents findings/recommendations to the Quality Improvement Committee and other committees as appropriate, and deploys actions as approved.Participates as needed in various UM or QI committees and work groups convened to improve process and/or health outcomes, and contributes meaningful detail, based on functional knowledge.Serves as knowledge expert for continuous quality improvement activities.Leads and facilitates performance improvement teams in the development of activities to address identified barriers in arriving at desired outcome.Assists in activities to prioritize clinical and service improvement initiatives.Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met.Conducts internal auditing of compliance with regulatory and accreditation standards.Ensures that documentation produced and/or processes conducted comply with state regulations and/or accrediting body requirements.

HRCM:The High Risk Care Manager’s (HRCM) role is to provide intensive case management services to high risk members. High risk members include patients who are not coach-able and may lack family support, have multiple co-morbidity, frequent re-admissions or re-admission with certain high risk diagnosis/ DRGs. This role is responsible for assuring the member receives all the necessary treatment and resources following post-acute care hospitalization to allow the member to remain outside the acute care setting. They provide clinical oversight and direction for an efficient and comprehensive care plan. The HRCM acts as the member’s advocate during the acute care discharge process and for the defined risk period post hospitalization.ICC (TCC) SICC: ICC-(TCC) ans SICC are responsible for processing authorizations per protocol and monitor the care needs of enrolled individuals admitted to either a skilled nursing or rehabilitative facility. TCC's authorize PAC services according to approved clinical coverage criteria. Perform an admission, interim and discharge assessments. By serving as the link between members and the appropriate health care personnel, the ICC(TCC) and SICC is responsible for ensuring efficient, smooth, and prompt health care services are approved and delivered to the member. Provide discharge planning for transition to lower level of care and avoid re-hospitalizations.

Greater Pittsburgh Area

Case Manager, Q.I. Supervisor and Director of Patient Services in the home healthcare setting. Numerous duties that included being a full time case manager in home health . Also experienced in the supervision and quality of the home health team. Experienced in Oasis, coding and CMS regulations. High acuity RN with ventilator, wound vac, IV, wound care, feeding tube/pump and education of disease processes.

Greater Pittsburgh Area

U.P.M.C. ICU Registered Nurse, U.P.M.C Internal Vital Staffing Registered Nurse and U.P.M.C Private Duty Registered Nurse working with high acuity patients on ventilators.U.P.M.C. Oncology Group/ Laboratory prior to Nursing Career.

Prerequisites / Registered Nurse, Registered Nurse, 4.2

Registered Nurse, Nursing, 4.2

Activities and Societies: Numerous Nursing honors and scholarships provided to me during my attendance at St Francis S.O.N..

Critical Care, R.N.C.C, 4.0