Sandy Santangelo, Bsn, Rn Email and Phone Number

Coordinates all survey activities to maintain accreditation, certification and licensure. Chair for the Continuous Quality Improvement Committee, participates in all Quality Committees. Oversees Medical Appeals, Oversight of Staff Quality, Responsible for InterQual training for the Care Management Staff. Resource and SME on NCQA Accreditation. Clinical lead for GPRO data collection. • Support infrastructure investments, organizational and clinical redesign efforts that enhance care integration and coordination strategies to improve quality reporting and performance.

Responsible for independent research and communication of disease processes, prevalence, costs, and standard medical treatments through evaluating professional published materials for evidence based analyses.Assessment of medical management processes, evaluating outcomes and directly working with payers to improve processes through redesign strategies, with a focus on admission appropriateness, improved denial management and length-of-stay reduction.Research and provide written communications on various projects. ( Ex. healthcare reform, life care plans)Provide comprehensive standard and custom training of the Milliman Care Guidelines to licensees of the various products.

Manager of Utilization Management AppealsResponsible for the management of the medical appeals units in Penn Plaza and Mount Laurel offices for a total of 34 staff members.

Responsible for the overall management of the Appeals department. Managing the relationship between the company, provider and insured, ensuring high quality Appeal services are provided to multiple customers. . Accountable for investigating and the implementation of workflow to make certain state and federal regulations and URAC requirements are met. Responsible for implementing workflow for new clients utilizing our Specialty Physician Review. Preparation and presentation of quarterly reporting to internal committees and external clients.

Collaborates with the Vice President of Medical Management and serves as CareAdvantage, Inc. provider relations liaison to our major client's hospital network and participating physician group. Communicate goal and results of hospital performance assessments to administration and staff of the network facilities. Developed "Primary Care Management" programs that were presented to participating primary care physicians throughout the state of New Jersey.Managed the Appeals team and process, assuring guidelines and regulations were met.

Supervise a staff of 19 clinical and non-clinical personnel. Oversee the utilization management operation for 36 Blue Cross Blue Shield of New Jersey hospitals. Supervise and participate in all administrative and operational procedures. Interface with providers and customers on a daily basis, including hospital administration, Blue Cross Blue Shield of New Jersey provider relations, customer service personnel, and divisional leaders. Regularly meet with hospital utilization, case management, admitting, finance, physician leadership and hospital administrators regarding CareAdvantage utilization management activities, workflow issues and education.

Assigned to a 43-bed adult oncology unit with direct responsibility for providing highly technical care to acutely ill oncology patients. Additional responsibilities included: admitting, transferring, chart auditing as well as interpreting the care and needs of unstable patients. Coordinated nightly assignments of the staff and maintained and updated computerized patient records. Provided both physical and emotional support to the patients and families, which was frequently accompanied by patient and family teaching on issues relevant to the oncology patient. Often assigned as charge nurse, overseeing a staff of 15 and 43 patients. Acted as a liaison between the patient and health care providers, and performed discharge planning.

Responsibilities included direct patient care on a 43-bed oncology unit. Provided emotional support to patients and families. Identified patient discharged needs. Also participated in oncology group meetings.