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Amicha
amikelly027@gmail.com
904-705-3369
531 Falkland Circle
Clarksville, TN 37042
17 years experience W2
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Summary

Experience
Apr 2021 - present
(Remote)
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QI Stars RN Reviewer -Healthcare Quality and Improvement, HEDIS Project
Medical Devices
Jan 2021 - Apr 2021
  • Team member of the Quality Improvement-HEDIS team working with internal and external partners on the clinical quality improvement for Annual HEDIS Project.
  • Responsible for research, obtaining medical records and the review of medical records according to established guidelines.
  • Perform medical chart reviews where necessary to support improvement and compliance related activities.
  • Perform medical record reviews to support improvement and compliance, abstract HEDIS data, to include over-read of reviews, working collaboratively with internal HEDIS Team and the Quality Team.
  • Perform administrative functions to include medical record request, faxing and calls to members and providers as needed. Maintain organized, updated reporting of activities with clear documentation.
  • Complete claim research to identify the service performed, dates of service, provider type, and place of service. Research may include multiple systems and reports.
  • Participate in the activities of the Quality Improvement Annual HEDIS Program. Work collaboratively with internal and external management and resources (staff and contractors) to optimize the HEDIS rates.
  • Utilize multiple systems to perform research, data abstraction and entry to review for compliance of NCQA measures.
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Clinical Supervisor
Information Technology
Jun 2019 - Jan 2020
Nurse Liaisons
  • FL Post Acute Care
  • Supervise Post Acute Care team members, providing support and guidance for patient centered interventions. Oversee daily workload and make assignments to ensure timely completion.
  • Functioned as a Subject Matter Expert (SME), resource and support for all staff members providing training, resources, and tools to ensure the success of my staff.
  • Monitor performance and productivity of team and individual members and take appropriate actions to ensure guidelines and departmental goals are met. Work collaboratively with provider relations, provider networks, internal department leads, marketing and clinical management to implement best practices for care transitions, utilization and authorization of management of selected services.
  • Work directly with Product Development team to improve process and procedures to improve workflow for nursing staff to increase efficiency, improve patient outcomes and nursing satisfaction.
  • Supported the effective rollout of the PAC program in the state of Florida with 2 payer sources.
  • Utilize MCG care guidelines for Utilization/medical reviews for patients.
  • Recruited, interviewed and trained top talent to serve as Nurse Liaison staff.
  • Participated in 6-week new hire training program of new team members and transfers.
  • Provide education to team members on HEDIS and NCQA quality measures, ensured they documented these appropriately within the patient's chart. COVENTRY
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RN, Field Case Manager
Dec 2018 - May 2019
  • Liaise between patient/family, employer, providers, insurance company and healthcare personnel to assess injured employees and identify needs required to facilitate the timely and appropriate return to work.
  • Generate individualized care plan to achieve recovery outcomes interview patients to provide ongoing case management towards the accomplished of established goals.
  • Facilitate referrals for specialized care as needed confer with providers concerning prognosis and course of treatment progression.
  • Administer educational and prevention programs on diverse health topics. Collate and generate all required documentation of casework activities in compliance with all laws and regulation applicable to the provision of rehabilitative service.
  • Efficiently managed claims to minimize cost and missed time from work for employees.
  • Quickly learned charting system including key billing procedures to ensure time and cost management.
MS Visio
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RN Case Manager
Medical Devices
May 2016 - Nov 2018
  • Made outreach calls to members currently or recently hospitalized to determine needs and engage for Case Management support.
  • Implemented short term case management for patients and family, to ease the transition from hospital to home and monitor adjustment to care. Utilized Motivational Interviewing to engage patients and family daily.
  • Provided post-discharge education and support to patients on their diagnosis, medication, and required follow up appointments. Performed medication reconciliation after discharge and each doctor appointment.
  • Identified and troubleshoot gaps in care to assure that patient received optimal treatment to achieve recovery objectives.
  • Adjusted identified needs and care to make appropriate referrals to Matrix Partners. Interacted with Case Managers, Social Workers and nursing staff to facilitate discharge planning that will achieve patient care needs.
  • Managed cases through to closure or referral to another partner when advanced care was needed to meet customer requirements.
  • Served as a preceptor for new employees to promote autonomous and critical thinking and independent practice while facilitating safe and efficient operations for patients.
  • Recognized as TruCare Subject Matter Expert.
  • Utilized MCG guidelines to utilization reviews for commercial members.
  • Collaborated with project management team to satisfy and uphold URAC quality standards.
  • Worked with patients and providers to ensure HEDIS measures are met and documented in Cigna system
Project Management
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RN, ACO Aligned Embedded Care Manager
Oct 2015 - May 2016
  • PIONEER VALLEY FAMILY MEDICINE RN, ACO Aligned Embedded Care Manager
  • Championed the coordination of care for patients with an emphasis on improved access and availability of services based on HEDIS measures and requirements of ACO.
  • Maximized organizational operations by effectively managing costs to improve outcomes and patient experiences.
  • Established Individualized Care Plans to identify needs and interventions of each patient monitored and evaluated implementation and adapted when necessary to ensure positive outcomes. Facilitated transitional care for patients and provided comprehensive education and outreach to avoid future hospitalizations. (Relocated back to Florida)
  • Streamlined office operations to exceed key HEDIS performance metrics related to appointment and testing scheduling.
  • Worked with providers on HEDIS measures to ensure all patients had completed tests, labs and other measures to meet HEDIS measures. Responsible for documenting all completed HEDIS measures within patient charts and marking the charts of patients who still had outstanding HEDIS measures to complete. Made outreach calls and completed letters to send out to patients to remind them of outstanding tests needed to complete measures.
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RN
Medical Devices
Dec 2014 - Jul 2015
Care Manager
  • Regional Team Lead
  • Led a team of 25 Field Case Managers (FCMs) overseeing 285 members for a third-party insurance carrier.
  • Evaluated patient's treatment plan for appropriateness, medical necessity, and cost effectiveness modified plans as necessary to comply with patient status.
  • Monitored and recorded client progress against established measurable goals in the individualized care plan. Supervised and directed associate's work processes.
  • Conducted weekly chart audits to ensure that all Case Managers were in full operational compliance with organizational, local, state, and federal guidelines.
  • Provided education and oversight to Field Case Managers on the assessment, planning, implementation, and evaluation of patient progress per insurance carrier protocols.
  • Aided Case Managers in locating community resources to assist patients in recovery from their diagnosed illnesses.
  • Implemented weekly chart reviews to meet URAC established guidelines and standards.
  • Recruited and on -boarded top-tier talent to serve as Field Case Managers who assured continuity of care and patient education to decrease readmissions.
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Mar 2013 - Dec 2014
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Director of Nursing, RN
Medical Devices
Nov 2011 - Mar 2013
CAMELLIA AT DEERWOOD
Project Management
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RN - SICU
Medical Devices
Nov 2005 - Nov 2011
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Edit Skills
Non-cloudteam Skill
Education
SSLP, MSI
not provided 2019
Nursing ASN
St. John's River State College 2011
Licensed Practical Nursing
Florida State College of Nursing 2003
Registered Nurse & Case Management Professional Profile
not provided
Certifications
KY. * Certified Case Manager (CCM)
CREDENTIALS & CERTIFICATIONS
Multi-state, Compact RN License Florida 9332342 (Active)
Certified Case Manager (CCM) The Commission of Case Management (CCMC)
Certified Six Sigma Green Belt (CSSGB), MSI
Florida Licensed Practical Nurse
Skills
Project Management
2021
11
Compliance
2021
4
Medicare
2013
1
MS Visio
2019
1
Billing
2012
1
Medical Coding
2012
1