Abigail De Guzman

Experience

• 

  Lakeshore Mental Health Institute

  Jan 2010 - Jun 2010

  Licensed Independent Practitioner
• 

  Statcare Medical Group

  Jul 2010 - Dec 2018

  Hospitalist

  I provided quality direct care for up to 30 patients daily with complex medical issues including CHF, GI bleeds, DM, CAD, COPD, PNA, CVA, and sequelae. Performed consultations for specialists and oversight of 9 patients additional with nonphysician providers. • Achieved high patient satisfaction scores by working with hospital medical staff to optimize clinical outcomes. • Handled ER admissions and direct transfers from outlying hospitals in Knoxville and surrounding rural facilities. • Coordinated with case managers and allied health professionals for cost effective transit through hospitalization, reduction of readmission, and community follow up for vulnerable populations. Show less

• 

  Tennova (formerly known as Physicians Regional Medical Center)

  Jul 2012 - Dec 2017

  • Department of Medicine Executive Committee Secretary

    Jan 2013 - Dec 2017

  • Medical Director Transitional Care Unit

    Jul 2012 - Dec 2016
• 

  Humana

  Dec 2018 - now

  I was promoted into this newly created leadership position to recruit, hire, develop, and oversee a centralized Inpatient Rehabilitation Facility (IRF) Team of Medical Directors (MDs) develop new processes/procedures, optimize quality of patient care delivery, and drive revenue growth. (New position was established based on success with the national Long-Term Acute Care Hospital Pilot). • Started the IRF Team with 3 MDs and built a top-performing team by recruiting/hiring another 10 MDs by December 2024 to manage high volume Acute Inpatient Rehabilitation operations. • Produced an immediate impact by creating a new onboarding/didactic model for this new MD function, writing the handbook/manual to define workflows/roles, and handling all training for the IRF Team. • Surpassed financial goals in first 3 months, achieving multi-million dollar savings at 240% of expectations. • Demonstrated team’s excellence regarding revenue impact, goal attainment, and quality by requesting team audits at 10% per MD/day (markedly higher than usual enterprise assessments) and championing a value-driven culture. • Hired a team of highly qualified administrative professionals by collaborating with analysts to accurately model and predict the need for this type of employee. • Maximized MD performance by developing a scorecard to remove subjectivity during biannual performance reviews and ensure accountability, define expectations, capture results, and emphasize quantity/quality of completed work. • Leveraged analytics with daily use of Power BI to track trends/revenue of each MD’s determinations in the setting of Grievance & Appeals and third party (Maximus) to optimize IRF framework. • Collaborated with Humana business segments to develop a unified approach for handling IRF cases to benefit members that included educating each market regarding approach to Medicare compliance, operational efficiencies, and quality metrics. Show less I managed, mentored, developed, and scheduled 20 Medical Directors and optimized performance for the Gulf South region (TN, LA, AL, MS, VA). I led the team of Medical Directors conducting clinical case reviews of Medicare Inpatient, Post-Acute, and Pre-Authorization Cases to interpret/determine appropriateness of services received by Humana members. I was responsible for identifying/driving patient medical management operation treatments, maintaining regulatory compliance, monitoring regional operational/utilization management metrics, developing new clinical initiatives, and promoting collaboration within the regional medical management team. I also adjudicated on Medicare Advantage authorizations for all care levels based on medical necessity and coverage policies. • Spearheaded regional change management during 2023 corporate realignment that doubled the team to 20 Medical Directors. Earned high bonuses for the year by consolidating 2 large teams, establishing best practices, meeting with each team member to discuss changes, and establishing a collaborative culture. • Produced an immediate first year impact in 2022 and earned top performance bonuses by maintaining a fully staffed Department of 12 Medical Directors, optimizing efficiency, and ensuring attainment of regional metrics. • Led region to being awarded high-profile Long-Term Acute Care Hospital Pilot. I established quarterly audit procedures and implemented training to ensure compliance with 2024 Centers for Medicare and Medicaid Services guidelines. • Assisted in recruiting, hiring, and onboarding 10 Medical Directors, including 4 that are top ranked in the company. • Selected for leadership committees including assisting with Enterprise XSOLIS AI strategy, assisting with CMS 2 MN, working on AI automation of case disbursements, and collaborating with offshore partners for new efficiencies. Show less I was recruited for this position to perform medical interpretation and decisions regarding services provided by other healthcare professionals utilizing strategies of policies, procedures, and performance standards. • Won 2021 Humana Century Award and 2020 Humana Star Award for outstanding performance. • Key contributor to Humana’s transition to “Work at Home” (WAH) model by developing team engagement strategies via team’s chat to foster collaboration/teamwork during pandemic and for WAH integration. • Contributed to success of the 11-member Mid-South team by troubleshooting and guiding operations, serving as a resource for RNs and Reviewing MDs, and assisting the team in navigating unforeseen events. • Collaborated on Humana initiatives including Dispatch and SNF at Home to ensure alternative levels of care from 3rd party healthcare providers (outside of hospital setting) were reasonable and medically necessary. • Improved the organizational culture by serving as Wellbeing Co-chair & Founder of Midsouth Rocks Day (unofficial holiday for Mid-South market to celebrate associates) and by developing Progress not Perfection (initiative to establish a new mindset for making progress without the pressure of achieving perfection). • Engaged in processes that streamlined workflow and increased cohesiveness of Mid-South RMDs. 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  • Lead Medical Director, Acute Inpatient Rehabilitation

    Oct 2024 - now

  • Lead Medical Director

    Jan 2022 - Oct 2024

  • Medical Director

    Dec 2018 - Jan 2022