Experience

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  Humana military/humana insurance

  Nov 2007 - Oct 2009

  Utilization review supervisor

  • Supervision of Utilization Review Management operations for 15-23 associates of the Active Duty Unit and the Clinical Intake Team (Registered nurses).• Monitoring operations and providing oversight and coordination to ensure smooth and timely clinical case reviews, discharge planning, referral management, claim review, benefit interpretation, network steerage and authorization processing for active duty service members from all branches of the armed services including NASA’s astronauts and individuals serving with the National Oceanic and Atmospheric Administration (NOAA) as well as, commercial and Medicare members. • Use of Visio Software, Excel, Outlook• Tracking cost savings through the Utilization Review Process.• Manage staffing patterns which include hiring and terminations of individuals as needed, coordination with Tricare Service Centers /regional markets and efforts to ensure successful productivity measurements of the unit. • Creation of tools that ensure more accurate data driven information so that associates can understand standards they are measured against with better accuracy. • Auditing of Patient Care Coordinators/Clinical Nurses authorizations, training of Health Care Finders/specialist.• Preparation with upper management for Utilization Review accreditation audits.• Other duties as warranted and necessary to ensure smooth operations of the UM call center. • Software used: Excel Spreadsheet, PowerPoint, Microsoft Outlook and Microsoft Word. Show less

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  Amerigroup

  Oct 2009 - Jun 2010

  Case manager/utilization review nurse

  • Sole Medicare case manager for the San Antonio plan. Providing leadership in helping to retain Medicare population and providing continuous membership education and provider education regarding the plan. Actively working with management to calculate goals and strategic planning for the growth of San Antonio membership.• Utilization Review to help contain cost for the Special Needs Population of Medicare.• Medical guidance for High Risk Medicare/Medicaid members of the insurance as it relates to quality health care.• Effectively Case Manage members of the insurance plan and help to drive down cost while maintaining quality health care standards for members of the insurance plan.• Collaborates with the members PCP and specialists in the development of the plan of care to ensure that member’s physical needs are addressed.• Establishes working relationships with referral sources and community resources.• Establishes short and long term goals in collaboration with the member that meets member’s needs and the referral sources requirement. • Evaluates quality of necessary medical services.• Identifying members that would benefit from an alternative level of care.• Utilize leadership skills for non-clinical team members• Microsoft word, Excel spread sheet and other internal computer program skills used. Show less

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  Care improvement plus - united health care

  Jun 2010 - Mar 2012

  Utilization review nurse/case manager

  • Utilization review for Medicare Special Needs population. Accessing appropriate levels of care across the continuum for the member of Care Improvement Plus. • Disease Management for members with Chronic Obstructive Pulmonary Disease and other disease states. • Provides ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient/member needs.• Collaboration with social services and the members PCP for development of a good plan of care to help ensure quality medical care and to help address psychosocial issues.• Coordinate the integration of social services/case management functions into the member’s care. • Discharge and home planning process with the hospital, external service organizations, agencies and healthcare facilities. • Collaboration with the Utilization review department to help identify high risk members who have frequent hospitalizations. • Serves as a patient advocate. Enhances a collaborative relationship to maximize the member and the family’s ability to make informed decisions. • Identifying members that would benefit from another plan within the CIP host of plans that may better serve the member. • Helping with member retention by reporting to various departments within CIT if member needs are warranted. • Milliman Care Guidelines and Interqual utilization review programs used.• Excel spread sheet, Microsoft word, PowerPoint and internal program systems used • Other duties are required. Show less

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  San antonio military medical center

  Mar 2012 - Sept 2013

  Rn case manager

  • Provide assessment, planning, implementing and coordination of care to a caseload of 20-25 wounded warriors who served in the Iraq and Afghanistan war in an outpatient setting.• Weekly meetings assessing the needs of the solders and family members.• Weekly verbal reporting in the TRIAD of care meetings of each solder’s full health care status and any medical care needs that are lacking or preventing the solder from full recovery. • Monitoring and resolution of coordination of care of soldiers related to disease states, behavioral health issues and trauma injuries that is not resolved. Family issues that are a result of war and other solider concerns as needed.• Referral to community resources, monitoring of living conditions on post and off post, suggestions of medical care changes that may need to be implemented in the best interest of the solider to the care team, etc. • Advocate for the wounded warrior as they progress through the continuum of care.• Monitor and update the command unit of the soldier’s transition to retirement from the U.S Army or return to their prospective duty stations.• Continual communication with the care team including specialty providers and close communication with the PCM for updates on the soldier’s status. • Referral to the solders local Veterans Administration for discharge planning and continued plan of care. • CPR certified.• Use of Excel Spreadsheet, Microsoft Word, Microsoft Access, Outlook and PowerPoint. Other DOD programs used. Show less

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  Baptist health care system- tenet

  Oct 2013 - Nov 2014

  Senior rn case manager

  • Responsible for coordinating, developing, executing, monitoring, and evaluating all Case Management activities. Case Management activities encompasses clinical utilization review, resource management, coordination of care, transition/discharge planning, and social workServices across the episode of care. • Working in collaborative practice with the physicians and multidisciplinary team members to meet patient-specific and age-related patient needs, linking cost resource management and quality of patient care. Other related duties as assigned.• Resource for newer case managers and team members for complex placements or difficulty utilization review cases.• Critical thinking skills for correct placement of patient’s.• Multisystem computer use inclusive of the Interqual program for utilization review• Other duties as assigned Show less

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  Baptist healthcare system, san antonio, texas

  Nov 2014 - Jul 2016

  Regional director of transitions of care

  • Developed and maintains processes and procedures to ensure that Congestive Heart Failure (CHF), Acute Myocardial Infarction (AMI), Pneumonia (PN) Chronic Obstructive Pulmonary Disease (COPD), Total Hip Replacement (THA) and Total Knee Replacement (TKA) patients are being educated while in-patient and monitored in the post- acute phase of the hospitalization. This effort is in relation to the Bundled Payment Care Initiative (BPCI) for Medicare beneficiaries with a goal of decreased hospital readmissions across the region ( 5 hospital facilities)• Implemented the post-acute process for Transitional Care• Implemented the 24 hour nurse line for the Baptist Health System• Developed “Code 30” initiatives to help reduce Emergency Department readmissions when applicable within the region• Develops and manages the annual department operating and capital budget • Directs daily operations of assigned department/s Directs performance of staff • Maintains objectivity in decision making, utilizing facts to support decisions • Presentations given to the regional hospital presidents and CEO of the organization regarding readmission trends• Manages to eliminate boundaries to achieve integrated, efficient and quality service• Other duties as warranted Show less

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  Metropolitan methodist hospital

  Jul 2016 - Jun 2021

  Director of case management

  Directs and manages the operation and activities of the Case Management Department, including Utilization Review, Social Work and safe discharge planning. Directly responsible for the overall management of the department's daily operations to achieve quality improvement goals, fiscal productivity, patient satisfaction goals and objectives established by upper management. Responsibility for staff performance and the development of departmental goals in accordance with the hospital, case management practice and regulatory requirements. Collaboration with all disciplines, departments, payers, system partners, vendors and community agencies. Show less

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  Methodist healthcare system

  May 2021 - May 2023

  Vice president of clincial operations
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  Methodist speciality and transplant

  May 2023 - now

  Associate chief nurse officer