Kathy Carpineto

Experience

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  Alere Inc.

  Oct 1998 - Jan 2012

  Team Manager

  • Primary contact for clinical operations and relationship of employer groups and health plans.• Interviewing, orienting, training and ongoing evaluation of Care Managers and Care Support Managers.• Managed approximately 55 plus nurses.• Interfaced with client clinical liaisons to respond to customer needs and develop most efficient and effective operational processes.• Worked closely with other clinical team members on case assignment and workload balance of Care Managers.• Monitored and reviewed documentation of clinical team to ensure appropriateness of care and utilization review• Acted as primary liaison between clients services executive and internal/external clinical team members.• Escalated client-specific process, quality and legal issues in a professional and expeditious manner.• Coordinated and conducted monthly internal team meetings and quarterly customer in-service/case presentation meetings.• Maintained relationships with community providers and other organizations in order to promote program awareness and direct referrals.• Worked with Client Managers closely and presented year end reports and assisted with day to day management and needs. RN Care Manager1998-2001• Directed and guided complex injury/illness cases by ongoing patient assessment, coordination, and facilitation of approved recommendations with emphasis on quality of life and cost effectiveness. • Provided patients with information on disease process, researched clinical trials, assisted physicians with treatment plans, assisted patients with disability process, and researched and connected patients to community resources. Show less

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  Paradigm Management Services

  Oct 2011 - Nov 2012

  Network Development Specialist

  • Identify businesses and individual nurses through recruitment methods and through the interview process.• Conduct onsite initial orientation training• Provide ongoing training and development for network managers.• Develop new training materials and create modules for Nurses.• Provide supervision and precept network managers and provide overview of documentation to ensure standards and protocols are met.• Assist with training programs for the global network including monthly bulletins and conference calls and other company sponsored training programs.• Assist with implementation of program enhancements that include collaboration with IT department.• Participate in quality audits, review of all policies and procedures, and teaching manuals and guides. Show less

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  Inventiv Medical Management

  Nov 2012 - Jan 2014

  Director, Clinical Services

  • Identify “wellness continuum” opportunities and develop successful blending of case, disease and medical management functions. • Oversee the Utilization, Disease Management, and Case Management Department that includes Clinical Managers, Registered Nurses, Administrative staff, Dietician, and Social Worker. Virtual and on-site team.• Collaborate with CMO in assuring processes are in place to accomplish all defined goals and quality metrics. • Created and wrote policies and processes for successful URAC accreditation with HEDIS quality measures 6/2013 for Disease Management and Case Management.• Communicate both vertically and horizontally regarding Care Management, Disease Management, and Utilization Management issues and changes. • Provide monthly operational reports of case management activities to Executive Leadership Team. • Responsible for assessment, planning, implementation, tracking, monitoring, coordination, reconciliation and evaluation of the managed care member’s performance across the continuum of care to include the complete transition of care to outpatient care. • Track and trend outcomes for potential improvements in the care management process and define metrics and objectives.• Evaluates and disseminates program and productivity reports weekly, monthly, and as needed. • Assist sales with on-site and remote presentations to clients. This includes providing case scenarios and clinical discussions.• Maintain relationships with community providers and other organizations in order to promote program awareness and referrals.• Work with Client Services and Executive Leadership team closely to assist with day to day management and needs.• Interview, hire, and retain quality nursing staff to meet the needs of the department.• Created a triage component for case management that increased engagement rate. Show less

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  XG Health Solutions

  Jan 2014 - Feb 2015

  Regional Director

  • Provides clinical/administrative oversight to Case and Disease Management for the Population Health Management Department of xG Health Solutions for both external and internal clients. Meets needs of new and existing business partners through delivery CM/ DM services. • Implementation and evaluation of all aspects of CM/DM to include the latest and most advanced evidenced based strategies as well as clinical knowledge. Work closely with xG Health Solutions Population Health Management Team to meet the needs of all clients. • Performs duties to support the goals and objectives of xG Health Solutions in its effort to assure the delivery of a quality product focused on the provision of excellent patient care in a cost-effective manner achieving a high level of patient and client satisfaction.• Directs the planning, coordination and execution of initiatives that promotes and supports the adoption of population health management.• Provides content expertise in conceptualizing, developing, and implementing CM/DM strategies and products using evidenced based best-practices and new technologies.• Assess CM/DM needs of new business partners/internal clients by conducting needs assessments; develops and ensures budget.• Develop and implements plans to meet client needs regarding the various aspects of Case Management services including referral, intake, eligibility determination, program planning, monitoring, and ongoing assessment.• Consult and communicate with client site leaders/physicians to evaluate CM/DM needs and implement services.• Provides oversight and direct management of CM/DM staff in region/regions assigned.• Recruits regionally for Case and Disease Managers to provide client services.• Develops/maintains policy and procedures related to case and disease management.• Ensures that educational programs are congruent with organizational missions, values and goals.• Provide support to platform enhancements for HEDIS, NCQA, and other quality measures. Show less

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  Centene Corporation

  Feb 2015 - Feb 2016

  Director, Medical Management

  Direct medical management program including utilization management, case management, quality improvement and credentialing in accordance with the mission, philosophy, and objectives of plan and in conjunction with Corporate goals and objectives.•Develop department objectives and organize activities to achieve objectives.•Evaluate and implement changes to medical service functions and performance in relation to company mission, philosophy objectives and policies.•Manage budget and forecast for strategic planning and key initiatives.•Coordinate with operating departments on research and implementation of best practices.•Responsible for the statistical analysis of utilization data on programs.•Participate in NCQA, State, and/or other accreditations of the Plan.•Organize and present new concepts, programs and tools to staff and other plan departments.•Develop communication plans with external providers such as hospitals and State agencies as required to facilitate plan goals and objectives.•Direct the overall operational leadership of case management functions and staff•Perform and oversee needs analysis and planning•Work with executive leadership to ensure targets are met for the annual operating plan/financial management•Develop and implement methods, policies and procedures to improve the departments efficiency and effectiveness Show less

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  Molina Healthcare

  Feb 2016 - Jul 2024

  • Utilize clinical expertise, review utilization information, and collaborate with providers to match those needs and care options for appropriate utilization. • Care coordination and facilitation with hospital discharge planners, case managers and hospitalist to obtain Post-Acute Care orders for engagement and continuum of care. • Provide clinical expertise to manage and train staff assigned to Post-Acute Care patients’ transition from acute care setting to the home setting through telephonic and face to face outreach to provide teaching methods. • Assists team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.• Provide clinical/administrative oversight and training to Transition of Care Coaches (Complex Case Management RNs) for a Medicaid population and Dual Eligible population.• Create workflows and work closely with leadership on outcomes and program.• Facilitated and implemented the Transition of Care program go live April 2016• Created a training day program and PowerPoint for staff on Transitions of Care and responsible for all training ongoing for Transitions.• Meet with hospitals and providers to review and educate on Transitions of Care Program and act as a Liaison for questions and issues.• Facilitate Multidisciplinary Team Meetings for high acuity members (Medical and Behavioral health) and participated in daily clinical rounds with MD and UM team for members in hospital/rehab/SNF for medical and behavioral health.• Assist Medical Director in maternity and NICU programs and attended all monthly state meetings for Birth Outcomes and Screening, Brief Intervention, and Referral to Treatment (SBIRT).• Develop relationship with providers and provide assistance with facilitating transitions, assisting with issues and escalating to appropriate departments.• Work with data team to create data and reporting on metrics for Transition of Care program Show less

  • Project Manager Special Projects and Eligibility

    Oct 2021 - Jul 2024

  • Manager Transitions of Care

    Feb 2016 - Jul 2024
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  Retired

  Jun 2024 - now

  Retired