Performed Assessment and re-organization of Medical Management at a major Medicaid Health Plan in Pennsylvania.Acted as interim leadership for over two years.Raised scores on URAC Case Management Evaluation from 47% to 97%.
Established Case Management Program and completely re-organized medical management at a Medicaid Health Plan in Michigan.Acted first as Director, then as Vice President of Medical Management for over 3 years. This included responsibility for quality management, utilization management, case management, and pharmacy management. Included involvement in government relations and provider relations as the medical management operations representative.
Completed an evaluation of a large Health Plan’s medical management program to identify strengths, weaknesses, and opportunities.Evaluation included an assessment of the plan’s readiness to implement a more proactive approach to medical management
Developed and implemented a high-risk case management program for a large (2 million member) Health Plan for Medicare Risk and Commercial Members.This included:
Evaluation of the organizational strengths weaknesses, cultural norms, and decision-making channels
Establishment and operation of several project teams to guide the development and implementation of the project, and to ensure organizational input and acceptance
Development of effective communication channels to ensure coordination and progress of the project.
Development of project budget and return on investment projection
Presentation of the project at various phases from inception to completion to diverse audiences from health plan staff to network physicians
Development of all policies and procedures
Assisting in the development of a database to capture data for various program reporting functions
Development and implementation of a three-day training program for case management staff, and full day training for medical directors and other medical management and administrative staff
Advising regarding communication of the project to all health plan staff, network physicians, and members
Compilation of a program manual
Integration of the new program into the existing medical management infrastructure
Interviewing all applicants for department
Assisting Human Resources in development of interview tool for case managers
Assisted in evaluation to determine the award of an over 1 million dollar grant proposal and site visit for a geriatric case management program
Provided technical expertise and authored the Policies and Procedures utilized by a large, highly rated Health Plan serving Medicare Risk and Commercial Memberships.The Policies and Procedures were subsequently presented to the Health Care Financing Administration as part of a successful site visit
Developed and implemented an outpatient case management program for a small, regional Health Plan
Performed an evaluation of a large multi-line insurer’s in-patient and out-patient case management program, proposed recommended changes, developed and implemented a project plan to implement recommendations.This included:
Development of policies and procedures
Implementing disease management protocols
Establishing a computer database to capture and report outcomes
Developing quality management tools
Development of documentation templates for use with a “legacy” system
Establishment of case management continuum of care rounds
Competency testing program
Training of the case management staff
Constructed and submitted questions for the Certified Case Manager examination.
Held voluntary position as Chairperson of the Council for Case Management Accountability, which published a landmark paper on patient adherence and outcome indicators in case management
Participated as a featured presenter and discussion group participant in a one-day program designed to provide direction in case management of the geriatric population to government representatives
Conducted educational and guided, goal-oriented discussions for a large, staff model Health Plan to prepare the primary care nursing teams for chronic illness and case management programs.Identified barriers to program implementation and suggested strategies for overcoming resistance
Assisted in establishing the inpatient and outpatient case management components for a large, multi-specialty medical group and Medicare Risk Health Plan that were implementing the first Medicare Risk Health Plan and Capitation program in the state
Invited by the Health Care Financing Administration to present principles of Case Management in relation to mandates under the Balanced Budget Act
Evaluation of the strengths and weaknesses of a mature, large (over 1 million) member Health Plan’s case management and disease management program..Including:
Conducting an in-depth evaluation of operations in multiple locations
Evaluation of current management staff
Identification of new, innovative strategies in an already very mature, sophisticated market
Development of a comprehensive set of recommendations and a detailed project plan to implement the recommendations
Formation of a client steering committee
Establishing standards for delegated case management functions
Refining policies and procedures
Conducted a training program for all case management personnel for a large Health Plan with Medicare Risk and Commercial Memberships.This included development of a tool to measure the outcome of the training by percent of knowledge increase pre and post training
Served as technical consultant for a large, well known, policy and research firm on a project awarded by the Health Care Financing Administration to identify and document “best practice” in coordinated care.This included:
Development of a tool to determine “process” scores for established coordinated care programs.The tool contained not only the standards but detailed guidelines for use by reviewers in determining the score
Conducting training and enhancing inter-rater reliability for the reviewers using the tool via case studies, mock interviews, and literature reviews
Developing a comprehensive interview guide for project participants
Conducting 1-2 hour interviews with project finalist
Providing a written summary of the interviews
Assisting with the analysis of the data and formulation of project conclusions
Review of all project reports to Health Care Financing Administration
Conducted evaluation of medical management programs and formulated recommendations for a large integrated health care system
Served as interim director for a large hospital system case management department which included:
Redefining roles and accountabilities of all staff
Researching , development and implementation of case management model
Developing departmental objectives
Development and implementation of process and instrument to measure degree to which objectives were being met
Mentoring of management staff
Team building
Training staff and management on case management, change theory, problem solving techniques, outcomes measurement
Communication of new departmental strategy and action plan to upper management
Assisting in recruitment of permanent director
Evaluation and refinement of processes that were ineffective or inefficient
Establishing agenda and chairing departmental management meetings
Spearheaded the creation and dissemination of CMAG (Case Management Adherence Guidelines), and conducted training in 37 cities across U.S. ; www.cmsa.org/cmag. One of two original Master Trainers for Health Behavior Change