Remote

• Provided telephonic Case Management and Care Coordination to members.
• Developed goal based care plans using nursing diagnosis while incorporating therapeutic, preventive and rehabilitative nursing actions to maintain wellness and avoid hospital readmissions.
• Identified knowledge deficits to prevent gaps in care and teaching and community resources.
• Analyzed data from the various care providers to identify under/over utilization and improve resource consumption.x

• Performed accurate Hedis medical record data abstraction and clinical review for all measures of compliance specific to Oncology..
• Prepared reports for management to utilize finding and trends to improve efficiency as well as customer satisfaction.
• Maintained HIPAA regulations for consumer privacy and completed tasks in a timely manner to ensure compliance with NCQA, federal, state and other regulatory agency standards.

Remote

• Monitored delivery of care to ensure all patient's needs were addressed.
• Specialized in women's health, Makena injections, and high risk prenatal care.
• Identified patient and family knowledge deficits and provided hands on teaching to improve patient outcomes and compliance
• Efficiently created patient centered care plans that include measurable, clearly defined goals.
• Performed telephone triage and used telehealth remote monitoring.

• Focused organizational efforts on the improvement of clinical quality performance measures.
• Coordinated with various data sources and medical units to streamline billing processes.Drove compliance based on CMS guidelines to improve work processes, quality, and increase outcomes.
• Guided quality improvement projects to review billing edits, modifiers and audit clinical documentation to ensure guidelines are followed with accuracy in CPT, ICD-10 diagnosis coding.

Remote

• Effectively Case managed Medicaid members who were high risk pregnancies. Performed Home visits, including home safety evaluation, fall prevention, and diagnosis specific assessments.
• Counseled members on hypertension, preterm labor, hyperemesis, gestational diabetes, hydration and IV infusion. Assisted in planning follow up care, teaching and prevention of worsening in condition.
• Coordinated with hospital discharge planning to set up services and ensure safe discharge home.
• Set up remote monitoring systems for members and performed daily checks on each enrollee to address any priority alerts and ensure health safety.