Amicha Duarte, RN, CCM

• Clinical Quality Management for VA Community Care Network
• Oversee the management of patient safety activities, including quality investigations, tracking and trending of quality issues, and provider corrective action plans (CAPs)
• Complete Case Reviews and bring findings to Medical Director for collaboration for presentation at Peer Review Committee (PRC)
• Ensure process for review and PRC is completed prior to committee review
• Ensure potential quality issue investigation process is completed through closure to meet contractual turnaround time requirements
• In depth knowledge of Standards of Care/deviations from Standards of care for multiple inpatient/outpatient and clinic visits/procedures to ensure patient safety is always maintained, at all levels of care
• Highly knowledgeable of AHRQ, HAC, HEDIS, and other outcome measures and analysis (identify, evaluation of, promotion, education, utilization) of best practice and quality measures to assist organizations in maintaining awareness of and support in developing a plan to integrate best practices to ensure, promote and continue quality care through the continuum and achieve and/or maintain any regulatory accreditations or certifications required by law
• Extremely detail oriented, ensuring patient-centered outcomes are the goal of all patient interactions and transitions of care
• Utilize Project Management skills (CLSSGB) to maintain my caseload by monitoring timeliness of case, initiating, planning and executing plans to maintain up-to-date reporting required by leadership
• Highly skilled utilizing multiple computer systems, toggling between multiple screens and systems and documenting all actions within an eMAR, claims system, VA, and other insurance providers to ensure all documentation is current, clear, and per requirements of leadership and all accrediting bodies
• Provide education to providers and staff on my role and the role of my team and company to ensure all needed documents are received in a timely manner to exceed turnaround times
• Review MRA/HCC coding for accuracy.

• husband in military, relocated to TN
• QI Stars RN Reviewer -Healthcare Quality and Improvement, HEDIS Project
• 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 for HEDIS research
• Perform medical chart reviews where necessary to abstract information and data 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
• Review claims for ICD 9/10, CPT, HCPCS Level II coding for Annual HEDIS year to ensure they meet quality metrics
• 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
• Utilized Sharepoint, Excel, Diamond (internal claims system), and other Florida Blue systems to organize, monitor and prioritize data and claims.
• Integrated decision support, clinical pathways and best practices into health information technology to enhance delivery of care and workflows.

(Received military orders to relocate)

• 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 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
• Provide QI/QAP support for Quality department from PAC team
• 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 Go-Live of SalesForce program in the state of Florida with 2 payor sources
• Utilize MCG care guidelines for Utilization/medical reviews for patients
• Employ benefits knowledge of Medicaid, Medicare and commercial payer contracts to make decisions on staffing needs as well as claims, reviews and other regulatory requirements
• 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
• Developed and presented training to staff for onboarding and for continued education, working with the product development team to improve working guidelines and practices for the best outcomes
• Utilized multiple systems for staff organization and communication: SalesForce, Sharepoint, Excel and internal claims systems as acting TPA (Third Party Administrator) for Florida Blue and Centene
• Provide education to team members on HEDIS and NCQA quality measures, ensured they documented these appropriately within the patient’s chart.
• Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.

• 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
• Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
• 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.

• Made outreach calls to members currently or recently hospitalized to determine needs and engage for Case Management support
• Took proactive approach to identifying opportunities for quality improvements
• On QI team to support SOP updates and training for peers
• 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
• Provide 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 troubleshot gaps in care to assure that patient received optimal treatment to achieve recovery objectives
• Adjusted identified needs and care and made 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
• Supported the effective Go-Live of the TruCare platform for Case Management documentation and training
• Recognized as TruCare Subject Matter Expert
• Worked with multiple systems to maintain project and team organization:
• Excel, Sharepoint
• Trained and attended multiple trainings throughout employment on the ins and outs of medical and mental health insurance
• Learning contract details, guidelines and laws specific to the payer
• Gained a thorough understanding of insurance contracts, rules, and language
• Collaborated with multiple teams on Mental Health Parity and substantial disorders laws, ensuring all patients received care for mental health and substance abuse disorders
• 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
• Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
• Responded promptly and professionally to patient questions and concerns.

• Relocated to Florida, husband military
• 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
• Worked with ACO and contracted providers on Mental Health parity to ensure large population with mental illness and substance abuse disorders were able to receive covered care and resources
• 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.

• 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.

• Monitored and evaluated nursing staff performance, providing feedback and guidance to support standards of care.
• Built and maintained positive working relationships with physicians and staff to support seamless healthcare operations.
• Oversaw and approved recruitment, hiring and orientation of new nursing staff.
• Participated in management team meetings to discuss resident status, census changes, and resident complaints or concerns.

• Delivered age-appropriate medical care for adult, adolescent, and geriatric SICU patients.
• Monitored patients' respiratory status and ventilator operation and made adjustments to promote stabilization.
• Observed patients' vital signs and administered physician-prescribed medications and treatments.
• Recorded patients' medical status and treatment details in electronic charts to accurately document medical care.
• Explained health care issues and ramifications to patients and families to promote informed medical care choices.
• Participated in SICU departmental quality improvement initiatives to achieve higher standard of patient care.
• Conducted patient assessments, recorded vitals, and analyzed records and charts to define care requirements.

• Managed medication cart and dispensed pills, oral therapies and intramuscular injections to patients on multiple floors.
• Administered nursing patient care and treatments by dressing wounds, treating bedsores, giving enemas and performing catheterizations.
• Communicated effectively with patients and family members to convey important instructions and discuss treatments.
• Administered medication such as insulin and monitored patients' responses to detect problems.
• Maintained accurate records of residents' healthcare treatments and responses.
• Established compassionate environment by providing psychological, emotional and spiritual support to patients and families.
• Modified patient health treatment plans by observing patient conditions and responses.
• Collaborated with healthcare team members to assess, implement and evaluate nursing care plans.
• Responded to patient requests with appropriate clinical and personal assistance.
• Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.