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Work Background
Carisk PartnersClinical Quality Nurse
Mar. 2024RemoteImplement auditing and quality assurance initiatives while developing and delivering training programs to ensure clinical teams meet key performance indicators.
•Conduct quality assurance (QA) reviews of patient case reports and coordinate findings with Clinical Team members
•Track and audit contracted workers’ compensation patient cases, focusing on outcomes, care coordination course, progress reports, completion reports, and quarterly reviews
•Perform critical clinical analysis of patient cases, identifying active problems, risks, and barriers to optimize care delivery and patient outcomes
•Develop, implement and conduct virtual instructor-led training sessions and materials related to key performance indicators (KPIs) for the clinical team, enhancing documentation standards, care quality, and overall team performance
•Develop quick reference guides for KPIs related to progress reports, completion reports, care plans, and documentation standards to improve team efficiency and consistency in reporting
Molina Healthcare of New York IncAuditor, Clinical Services
Nov. 2022 - Mar. 2024Conduct monthly audits of Care Review Nurses (CRC) and non-clinical staff using Molina’s internal audit tool and standard approach
•Monitor CRC staff compliance with IRR, clinical documentation and NCQA, CMS, State & Federal requirements
•Monitor and assess non-clinical staff phone interactions with customers to ensure compliance with established procedures and standards
•Maintain detailed audit records, report monthly outcomes, and identify areas for process improvement/re-education
•Collaborate with leadership to address findings and issues identified, working towards resolution
•Assist the HCS training team in developing training materials and/or job aids based on audit results
Molina HealthcareCLINICAL SERVICES TRAINER (RN) (Remote)
Jul. 2021 - Nov. 2022Implemented, facilitated, and conducted virtual instructor-led training & education programs for new and existing clinical and non-clinical staff to improve quality, control medical costs, and ensure compliance with regulations and guidelines
• Collaborated with training team and leadership to design and implement training content, materials, and technology for clinical & non-clinical staff, incorporating state-specific regulations
• Provide feedback on process and quality improvements, evaluating training effectiveness to maximize employee efficiency and performance
• Functioned as subject matter expert (SME) and resource for troubleshooting technology problems and specialized software applications for healthcare services staff
CignaQUALITY REVIEW & AUDIT LEAD ANALYST / CM-SNP CLINICAL TRAINER (Remote)
May. 2020 - Jun. 2021Conduct virtual instructor-led, end-user training for clinical and non-clinical staff, including new hire/onboarding training programs across the CM-SNP business teams
• Identified and assessed training deficits, coordinating team training, and monitoring corrective actions
• Provided input to clinical leadership teams on process flow design changes and developed process improvement initiatives for enhancing clinical operations and protocols
• Assisted in preparing and supporting those affected by change, monitoring transition, and evaluating results following deployment of new clinical protocols
EK Health Services, Inc.CASE MANAGEMENT TEAM LEAD (Remote)
Oct. 2019 - Apr. 2020Supervised activities of the discharge planning team, ensuring compliance with quality audit requirements through effective performance improvement activities
• Developed and facilitated ongoing education/training for case management staff
• Directed case management activities for injured workers, establishing rehabilitation objectives and medically managing client needs across course of care
Paradigm (formerly Restore Rehabilitation)QUALITY & PERFORMANCE MANAGER / CLINICAL TRAINER (Remote)
Aug. 2016 - Sep. 2019Served as subject matter expert (SME) for company-wide quality assurance & quality improvement activities, technology, and software application training curriculums, overseeing performance improvement activities related to URAC accreditation requirements
• Performed ongoing internal data audits, analyzing results for trends and root causes to recommend quality & performance improvement opportunities
• Led QA committee functions to implement performance improvement plans and report on outcomes
• Spearheaded the development of technology infrastructure to support quality improvement programs
• Collaborated with design & development teams to provide clinical input, ensuring appropriate data capture and documentation support
Delmarva Health Network at Beebe Medical CenterCHRONIC CARE MANAGEMENT (CCM) NURSE HEALTH ADVOCATE
Mar. 2016 - Aug. 2016Lewes, DECCM program eliminated in cost-cutting decision
Highmark Blue Cross Blue ShieldHEALTH OPTIONS MEDICAL CASE MANAGER (Remote)
Mar. 2015 - Mar. 2016Wilmington, Delaware, United StatesAssure high-quality, cost-effective healthcare to members with complex medical and psychosocial needs. Assess patient needs, coordinate and implement care plans, member education, training new staff, and collaborating with providers
Rising Medical SolutionsWORKERS’ COMPENSATION TELEPHONIC NURSE CASE MANAGER (Remote)
Jun. 2014 - Mar. 2015Chicago, Illinois, United StatesCoordinate care for high-risk, high-cost, and complex patients across multiple jurisdictions. Assess patient needs, coordinate and implement care plans, and monitor and evaluate the plan’s effectiveness. Utilize knowledge of medical necessity, care appropriateness, and managed care principles to ensure that care is both high-quality and cost-effective. Establish collaborative relationships and work as an intermediary between clients, injured workers, employers, providers, and attorneys.
First Rehabilitation Resources, Inc.WORKERS’ COMPENSATION TELEPHONIC/FIELD NURSE CASE MANAGER (Remote)
Dec. 2010 - Jun. 2014Laurel, Maryland, United StatesCoordinate care for injured workers in multiple jurisdictions, determining case direction, coordinating service delivery, implementing medical management, monitoring participating in rehabilitative programs, identifying patient-specific education needs, and precepting and training new staff.
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