244 Sheffield Chase
McDonough, GA 30253
(404)547-6787 (cell)
(678)272-2750
UniHealth Solutions Select
DIRECTOR OF INTAKE AND CONTRACTING JUNE 2008 UNTIL PRESENT
September 08 promoted to Director of Operations of Commercial Care Management
Company
Resigned November 09
Job Overview:
* FOCUS ON COMPANY STRATEGIC PLAN FOR DAY TO DAY OPERATIONS
* Staff education, training, hiring and firing
* Liaison between Skilled Nursing Facilities, Home and Hospice for all
commercial care management, insurance verifications, utilization review (denial
management oversight i.e. ADRs(Hospice), Managed Care Denials and Home health
Denials).
* Centralized Hospice Office -Office consists of Intact, verification of
commercial care management and facilitating placement of all referrals
* Contracting of Managed Care Contracts (see below)
* Oversight of all commercial managed care contracts, negotiations, letter of
agreements,
* education of all contracts, and credentialing of contracts
* Overall responsibility of verification of benefits of commercial managed care
payors for Home Health, Hospice, and Skilled Nursing Facilities
* Ensuring the Oasis assessments, and ADRs are handled appropriately for Home
Health and Hospice with oversight of my Utilization department
* Educating Regional Admission Directors on trends in managed care, census
development of managed care, and trouble shooting all managed care potential
issues as it relates to reimbursement, billing and denials on admission due to
not meeting medical necessity, etc.
* Communicate and oversee all daily Human resource issues within company
* Performance Improvement initiatives for company operations
* Implementation of Strategic Plans
* Working with collaboration of all Healthcare Centers to ensure understanding
of all commercial ancillary care management contracts, billing parameters and MDS
support
* Serve as representative for many company meetings as it relates to
development of software to enhance commercial case management i.e. CCMS,
reimbursement committee, etc
* Work very closely with CBO to ensure that hospice, home health and SNFs are
reimbursed appropriately per parameters of negotiated contracts for managed
care.
* Centralized Workers Comp case management also within this company (housed)
for corporate employees ( pilot program with review of SNFs)
* Oversight of budgets
* Review and education of policies
Kindred Healthcare
Regional Director of Managed Care December 2006 until June 2008
I am responsible for oversight of all managed care operations for the Central
Region for Health Services Division. I am responsible for negotiating contracts
for the SNFs with all MCO(s) to ensure that we are able to clinical and
financially meet the needs of MCO patients. I oversee MCO denials as well as
educating all facility SNF staff on concurrent review, UR and management of day
to day operations as it relates to the different needs of MCO. I review HCPC
codes, DME, Ancillary costs, inclusions, exclusions and Rev codes of all
contracts as well as review of collection of revenue as it relates to contract
and billing. I work closely with Regional Managers of Field Accounting and also
District Directors of Case Management to ensure all facility case managers
understand the difference in all negotiated contracts and teach facility case
managers to negotiate services for patients based on contracts. I cover a large
territory that encompasses GA, AL, TN, OH, KY, WI, IN, WI and MO. I assist
centers with individual letters of agreements, credentialing, on-site record
review of MCO and any billing concerns related to any managed care contract in
place. Work very closely with Sales and marketing to grow managed care business
within areas of operations needed.
Accomplishments- Developed a Managed Care Council
During the first year of employment have trained all case-managers on contract
negotiations, Letters of agreements and managing ancillary cost.
I also organized and put together a policy and procedure manual on managed care
for the region I am responsible for oversight.
Cypress Healthcare Management Company
Worked with Cypress from the year 2004 until 2008
Regional Case Mix Specialist - January 2006 to December 2008
This function oversees GA, LA (8 facilities) and TX (1 facility) with case-mix
functions. I oversee TILES payment system as well. I am well-versed on Quality
Indicators as well as the new quality measures.
Utilization Review/Case-Mix Specialist - August 2005 - January 2006
Primary functions: Oversee of the utilization review process in Georgia as it
relates to Medicare/PPS and ensuring Medicare Compliance.
Case-Mix Coordinator - March 2004 - January 2006
As the Case-Mix Coordinator I am overseeing 10 facilities across the state of
Georgia. I am responsible for teaching and training, auditing and implementing
systems to maintain compliance with Medicaid. I also assist facilities with
implementation of action plans as it relates to OBRA compliance. I am responsible
for ensuring appropriate utilization of Restorative Nursing and Rehab Therapy
services as it relates to certain disease management to provide quality of care
to residents with a need. I am involved with review of Case-Mix budgets and
oversight of MDS accuracy.
Accomplishments: Within the first year of employment I have established
quarterly lunch and learn meetings designed to inform and train all MDS staff as
well as DONs. I have reduced the RAI citations during Annual Surveys and all
buildings that received a citation cleared on first follow-up.
Accomplishments- the 2nd year includes the implementation of a Restorative
Council as well as a quarterly newsletter. I have implemented an MDS buddy
program as well. All facilities received 0 RAI deficiencies on annual survey.
MEDICAL CARE FOUNDATION-
1455 Lincoln Parkway
Atlanta, Georgia 30312
Clinical Utilization Precert Nurse- November 2003 - March 2004
Responsible for Precerting and prior Authorizing Inpatient and Outpatient
admission in Georgia hospitals for Medicaid patients. I reviewed all cases for
medical necessity using Interqual and review of ICD 9 codes. I also reviewed
cases for breast reductions, cataract surgeries, and foot surgeries. During my
tenure, I reviewed long term care DMA6 and Level 1 form for admissions into
nursing home helping determine level of skill need. I originally started working
with this facility through a staffing agency in November and was hired
permanent.
UNI-TER UNDERWRITING MANAGEMENT CORPORATION
1200 ASHWOOD PARKWAY, SUITE 560
ATLANTA, GA 30338
Risk Manager -December 30, 2002 - Nov.2003
Responsible for the risk management and clinical underwriting of the General and
Professional Liability programs, one covers long term care facilities in, CA, CO,
GA, IN, IA, IL, KS, KY, ME, MD MN, MO, NE, NH, NC, ND, OH, OR, RI, SC, SD, TN,
UT, VT, VA, WA, WI as well as Upstate NY. The other insurance program is a Risk
Retention Group exclusively for Florida long-term care facilities and ALFs. I
coordinated with the owners of these facilities to ensure that they are following
the correct guidelines. I am also responsible for holding the care plan
conference calls on each new insured under the FL RRG as well as reviewing state
surveys, help with writing plan of corrections, etc.
I offered risk management solutions on incident reporting, medical records
documentation, assistance with pressure sore documentation, etc. Review of
information for prevention of possible claims.
I am very familiar with loss runs, reserves, etc.
I am well versed in State agency guidelines as it relates to above specific
states.
KINDRED HEALTHCARE
District Director of Utilization Services - November 1998 - October 2002
Responsible for oversight of the Managed Care/HMO and Medicare Program for
states in Georgia, Alabama and LA. Oversee 3 states MDS/RAI process to ensure
accuracy.
Proficient in Quality Assurance/Performance Improvement initiatives and Census
Development in a long-term care setting. Oversee Long-term Care facilities in
the denial process and review medical records as needed for intermediaries. Also
I am very involved in oversight of budgets. I also was responsible for oversight
of ICD9 codes as well Intake review for DME. I am well versed in CMNs and also
taught the RAI process in the state of Georgia, Alabama and LS. I was also
involved in the Mock Survey Preparation to help facilities identify and monitor
medication administration, pressure ulcer treatment and investigation,
weight-loss management and documentation review, identification of clinical
complications i.e. dehydration, circulatory impairments as it related to certain
disease pathophysiology. I am well versed in state and federal regulations as it
refers to AL and LA/GA regulations. I am also responsible for oversee of budgets
and Profit and Loss. Involved in writing Plan of Corrections for state surveys as
well as execution of plans. Very proficient in PPS and dealing with CMS and
dealing with DAVE audits. I also was responsible for marketing with the rest of
the district team in terms of customer service. I went to lunch and learn
meetings with the Rehab Director to let case managers and discharge planners know
what we as a corporation could provide at the LTC facilities. Worked closely with
the marketing director to work on image out in community. Sat in on market calls
to work on retention of residents by maintaining satisfaction while staying at
facilities. Worked on PI initiatives as it relates to marketing needs i.e. market
materials handouts, etc. Worked with the facility DONs and MD to improve census
and maintain census with reduction of untimely discharges. Headed special task
force within the company to work on Quality Initiaves and maintained one of the
highest ALOS within the company. Also was responsible for rollout of Case-Mix in
the state of GA and training |
