Angela Wilson
Aurora,Il
Summary
A Professional Registered Nurse seeking a career opportunity in the management fast paced environment in a Managed Care Organization where there is an opportunity to collaborate and promote teamwork, maintain stability and promote quality of patient care in a patient focused healthcare setting. Professional Background: Extensive healthcare management role experience in the last 9 years: Utilization management Case management Acute patient care Complex Discharge Planning Utilization cost analysis Medicare and Medicaid Benefits Administration and Commercial Insurance Clinically complex cases Certified Case Manager (CCM) Collaboration with IDT Managed Care Principles Cross functional team management Policy/Procedure developmental and implementation HBR initiatives and planning Leader for 80+ employees Relationship and team building Achievements: Registered Professional Nurse for 15 years with experience in managing a team of people for Government product and private insurance for both Utilization and Case Management. Leader in implementation of a new MMAI program for members who coverage includes both Medicare and Medicaid for Utilization Management and Case Management Leader in implementation of a new Medicaid program for Youths ages 0-21 years under the Department Children Family Services in the Utilization Management and Discharge Planning Launched and coordinated a Continuous Quality Improvement (CQI) team which achieved improved outcomes on pay for performance measures, allowing health plan to recover withheld premium dollars. Instrumental leader in developing Medicare STARS quality program and a business leader for Plan Cause Readmission Measure Active leader on multidisciplinary team which developed Quality Improvement Plans (QIP) and Chronic Care Improvement Plans (CCIP) Extensive experience in ventilator dependent patients, acute care, hospice, and long term care an In-depth knowledge of the process and procedures of utilization management and hospice care services Working knowledge of InterQual guidelines. Proficient in MS Words, PowerPoint, Excel. Proficient in InterQual criteria, Trucare, Meditech Dedicated healthcare professional with history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Versatile Senior Manager specializing in UM/CM and skilled at planning, implementing and overseeing key improvements to drive business growth and efficiency. History of cultivating an open culture with free exchange of information. Pursuing new professional challenges with a growth-oriented company. Collaborative leader with dedication to partnering with coworkers to promote engaged, empowering work culture. Documented strengths in building and maintaining relationships with diverse range of stakeholders in dynamic, fast-paced settings. Forward-thinking Senior Manager adept at managing teams 3 employees with 104 direct reports to accomplish challenging objectives. Imparts clear vision to guide cohesive, high-performing teams.
Overview
15
15
years of professional experience
Work History
Senior Manager
Medicaid Medicaid Health Choice Illinois, Centene
2020.09 - Current
- Monitors, evaluates and provides ongoing feedback to staff, in timely manner, regarding work performance, incorporating performance improvement goals
- Oversee Utilization Management Committee and ensure adequate representation for UM on all work teams and committees
- Develop, recommend and manage department budget
- Administers quality standards that have been established for all Utilization Management, Care Coordination and support staff
- Oversight of clinical rounds both internally and with providers
- Assist with development, implementation, and updating approval process for yearly Utilization Management Plan
- Provide innovation and input to improve member care, operational efficiency, and regulatory compliance
- Provide weekly updates to Director of Utilization Management
- Assist with reviewing and updating UM policies and procedure
- Participate in provider and plan meetings as assigned
- Participate in provider and plan meetings as assigned
- Assist/monitor consistency amongst UM staff in application of Level of Care Criteria
- Managed over 80 employees both Inpatient and Outpatient and front line staff
- Identified cost improvement changes and cost savings plans to increase company savings
- Reviewed and analyzed reports, records and directives to obtain data required for planning department activities
- Provided strong leadership to enhance team productivity and morale
Manager UM/Transition
Illinois, Centene/Meridian/WellCare
2019.10 - 2021.09
- Responsible for development and implementation of UM program for startup product with Department Children Family Services and State of Illinois
- Collaborate on development and implementation of UM program to ensure State and Federal regulatory standards are met
- Develop and implemented UM processes and workflows in preparation of newly government product Youthcare
- Oversee and responsible for 35 staff inclusive of supervisors, prior authorization and concurrent nurses, support staff and transition of care staff
- Oversee all daily function of authorization call line, prior authorization, concurrent review and discharge planning both medical and behavioral health utilization
- Collaborate with providers on clinical issues and facilitate resolution
- Collaborate and partner with providers to decrease denials and improve outcomes
- Responsible for strengthening and maintaining hospital partnerships
- Participate in and manage utilization and quality objectives in accordance with departmental and company goals
- Prepare and present utilization management and discharge planning reports
- Compile and review multiple reports for statistical and financial tracking purposes to identify utilization trends and assist in financial forecasting
- Coordinate utilization management standards for preparation of NCQA accreditation
- Assist with reviewing and updating UM policies and procedures
- Facilitator for UM weekly rounds with IDCT including DCFS partners
- Accountable for ensuring monthly BMN care conference are conducted in collaboration with DCFS Caseworkers, facility personnel, Centene's Transition of Care specialists and Case Managers
- Weekly collaboration calls with HFS (State of Illinois) and DCFS on Transition of Care for Youths who has been identified with difficult hardships such as placement and medical necessity denials
- Developed and implemented Administrative Day Policy
Senior Manager
UM, Meridian/WellCare
2018.11 - 2019.10
- Responsible for oversight of 104 Utilization Management staff and program for both Inpatient and Outpatient utilization
- Responsible for ensuring compliance with all accreditation and state regulatory requirements
- Maintains appropriate communications within tn various internal departments and programs and participates on various internal committees and external meetings
- These committees include, but are not limited to, Medicaid Compliance, Accreditation, Care Coordination, Provider Network Development, Claims, Medical Policy Committee and State Operations departments
- Assists UM leadership with ensuring that all Utilization Management policies and procedures are updated at least quarterly, new policies are developed as needed and that all Utilization Management staff are appropriately informed/trained in updates and are compliant with Medicaid regulatory and accrediting requirements
- Assists UM leadership to ensure Utilization Management training initiatives are directed at meeting program goals and competency assessment is performed and compliant with Medicaid requirements
- Assists UM leadership with development and implementation of effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhance Utilization Management
- Ensure all utilization management decisions are based upon medical necessity, benefit determination, and scientific medical evidence
- Develop, plan, implement, and enhance processes within UM department to gain efficiencies and reduce costs while ensuring quality of care
- Build, promote and maintain strong partnerships with external providers
- Analyzes and reports data focusing on problematic areas and/or trends
Senior Clinical Manager
IlliniCare Health
2016.05 - 2018.11
- UM/Care Management Medicare, Medicaid/Ambetter/Medicaid, Oversee the daily operation functions of the Referral management, utilization review, prior authorization and case management functions
- Support and perform case management, disease management and concurrent review functions as necessary
- Provide support to Provider Relations issues related to Utilization for hospitals and providers
- Maintain compliance with NCQA standard and CMS regulations for utilization functions in the prior authorization
- Serve as the Appeal Nurse for Medicare beneficiaries requesting appeals
- Compile and review multiple reports for trends on Utilization Management
- Ensure compliance with performance measures appeals, denials, concurrent review timeliness and higher level of care admission certification
- Develop, implement and maintain utilization management program to facilitate the use of appropriate medical resources and decrease the business unit’s financial exposure
- Other experience provided below.
Clinical Manager
IlliniCare Health
2014.09 - 2016.05
- Daily prioritization of staffing assignments for optimizing impact on department production
- Responsible for managing all aspects of the denial and appeal processes within the department to promote consistency and accuracy within the processes and compliance with HIPPA, and regulatory and accreditation guidelines
- Conducts inter-rater reliability tests and audits among Nurse Reviewers, Pre-Service Nurse Reviewers, Transitional Case Managers
- Evaluates the consistency of utilization management decision making based on InterQual, Medicare and state specific Medicaid criteria
- Provide primary support to Medical Directors in the utilization review process
- Act as the primary resource in cooperation with the Medical Director and Director of Utilization Management for criteria and benefit interpretation including the correct and consistent application of InterQual criteria and the consistent application of procedural practices established by Centene, Medicare, and state specific Medicaid guidelines
- Identify, Implement and Evaluate process improvement activities
- Provide on-going coaching and counseling of all staff
- Promote the professional development of all staff .
- Oversee the discharge planning activities of the nurse reviewers, Pre-Service Nurse Reviewers, and Transitional Case Managers including but not limited to developing a plan of action, obtaining the necessary equipment and supplies, addressing discharge medication needs, referrals to disease and case management, negotiating prices, developing case contract, obtaining clinical updates, monitoring the number of days towards disenrollment and discharge planning from the SNF as well as post discharge calls to members
- Oversee the collection of Healthcare Effectiveness Data Information Set (HEDIS) information as is applicable to the differing job functions
- Actively participates in the Utilization Management/ Care Coordination weekly meetings by providing education and direction to the staff
- Oversee the coordination of care of potential transplant members including obtaining all necessary clinical information to determine appropriateness and medical necessity of transplant, presentation of case to medical director for approval, coordination of care for member across the continuum by appropriate case management referrals
- Solve utilization issues that occur by acting as the primary resolution point of contact
- Coordinates activities with other medical management departments as needed, including making referrals to Case Management and Behavioral Health
- Ensure Integrated Clinical Services staff is trained on NCQA, STARS and HEDIS measures and processes to ensure compliance
- Ensure all programs and clinical operations are in full compliance with state and federal regulations, including HIPAA
- Monitor the effectiveness of existing procedures and outreach/intervention efforts in demonstrating positive outcomes for members
- Ensure appropriate case planning, education and interventions are conducted for members defined to be at risk
- Ensure staff coordinates exchange of information between behavioral health and medical providers in developing comprehensive care plans for at risk members
- Monitor documentation, follow up calls to members are made in a timely manner according to acuity level
- Monitor data to address quality measures, trends or potential improvement opportunities including provider issues, service gaps and member needs
- Concurrent/ Prior Auth Review Nurse Medicaid and MMAI product
Concurrent Review Nurse
IlliniCare Health
2014.02 - 2014.09
- Performed all functions of Utilization Management, Case Management, and Disease Management
- Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
- Collaborate with various staff within provider networks and discharge planning team electronically or telephonically to coordinate member care
- Conduct discharge planning
- Consult with providers, physicians, members, and other resources to evaluate options and services to meet an individual health care needs
- Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
- Educate providers on utilization and medical management processes
- Consult with Medical Director as appropriate for all requests that do not meet criteria for admission and inform hospital reviewers of the Medical Director’s decisions
Inpatient Nurse
Westlake Hospital Seasons Hospice and Palliative Care
2012.01 - 2014.01
- Responsible for the care of hospice patients in accordance with the care plan established by the interdisciplinary team
- Acts as a liaison among the hospice patient, the attending physician, hospice medical director, volunteers and all members of the hospice interdisciplinary team
- Provides nursing care to hospice patients and their families on the inpatient hospice unit
- Responsible for closing records of discharged cases
- Participates in the coordination and facilitation of IDT’s
- Provide acute inpatient care and concentrates on the area of pain and symptom management
- Responsible for maintaining appropriate clinical and assessment skills
- Initiates discharge planning and coordinates hospice home nursing care with the hospice home team, facility and other agencies involved in the patient’s care.
RN Case Manager
Odyssey Hospice
2010.01 - 2012.01
- Conducts required initial physical assessment of patients and their family
- Coordinates the preparation of patient care plans
- Conducts periodic visits to the patients based on the patient’s level of need
- Problem solving skills
- Manage and supervise the delivery of service provided by Nurse Assistant and LPN
- Prepares patient care notes and ensures medical charts are up to date
- Attends and participates in weekly/monthly staff meetings
- Responds to patient and family requests in emergency and crisis visit situations
- Participation in Quality Assurance Program
- Triage emergency calls
- Case management of 10-12 patients, providing education, treatments, wound care and management of symptoms.
Staff Registered Nurse
Glenshire Nursing and Rehab Centre
2009.01 - 2010.01
- Assigned to Critical Care unit where ventilator dependent patients with broad range of physical conditions
- Coordinate/Implement individual treatment plans
- Responding to Code Blue/Crisis in a timely fashion
- Responding to Ventilator Alarms with Respiratory Team
- Implementing Physician orders
- Admitting/Discharging of patients
- Supervise the care provided by LPN and Nurse Assistant
- As a patient advocate, work collaboratively with medical staff and auxiliary personnel to address concerns
- Administered control narcotics assuming full responsibility for possession of keys, strictly adhering to regulations requiring the counting and charting of medications during change of shift
- Assess patients' clinical conditions utilizing non-invasive monitoring equipment including, SPO2, ventilator and defibrillator.
Staff Nurse
Provena St Mary Hospital
2009.01 - 2009.01
- Conducts an individualized patient assessment, prioritizing the data collection based on the adult or elderly patient’s immediate condition or needs within timeframe
- Develops plan of care that is individualized for the adult or elderly patient reflecting collaboration with other members of the IDCT
Education
Bachelor of Science Nursing - Nursing
American Sentinel University
Conneticut11.2022
Certified Case Manager -
Commission For Case Management
New Jersey05.2017
Skills
- Employee Performance Reviews
- Employee Coaching and Motivation
- Current Trends
- Professional Relationships
- Program Improvements
- Managing Multiple Projects
- Performance Tracking and Evaluations
- Employee Engagement
- Customer Satisfaction
- Staff Retention
- Process Improvement Initiatives
- Product Knowledge
- Corrective Actions
- Problem Resolution
- Performance Goals
- Discharge Planning Coordination
- Staff Management
- Interpersonal And Written Communication
- Goals And Objectives
- Documentation And Reporting
- Behavioral Health
- Recruiting and Hiring
- Regulatory and Statutory Compliance
- Quality Assurance
- Team Meeting Management
- Multidisciplinary Team Collaboration
- Critical Thinking
- Strategic Planning
- Long-Term Care
- Case Management
- Patient Education
- Professional Development
- Verbal and Written Communication
- Program Development
- Discharge and Transfer Procedures
- Nursing Ethics
- Leadership and Guidance
- EMR Software
- Performance Evaluations
- Effective Multitasking
- Business Operations Management
- Team Supervision
- Hospital Admissions
- Staff Evaluations
- Time Management
- Quality Improvement
- Practice Standards
- Public Speaking
- Chronic Disease Management
- Staff Scheduling
- Utilization Management
- Clinical Staff Management
- Problem Identification
- Profitability Strategies
Accomplishments
- Supervised team of 104 staff members.
- Registered Professional Nurse for 15 years with experience in managing a team of people for Government product and private insurance for both Utilization and Case Management.
- Leader in both Medical and Behavioral health UR and CM
- Leader for membership enrollment of 900k
- Leader in implementation of a new MMAI program for members who coverage includes both Medicare and Medicaid for Utilization Management and Case Management
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
swipe to browse
Timeline
Senior Manager
Medicaid Medicaid Health Choice Illinois, Centene
2020.09 - Current
Manager UM/Transition
Illinois, Centene/Meridian/WellCare
2019.10 - 2021.09
Senior Manager
UM, Meridian/WellCare
2018.11 - 2019.10
Senior Clinical Manager
IlliniCare Health
2016.05 - 2018.11
Clinical Manager
IlliniCare Health
2014.09 - 2016.05
Concurrent Review Nurse
IlliniCare Health
2014.02 - 2014.09
Inpatient Nurse
Westlake Hospital Seasons Hospice and Palliative Care
2012.01 - 2014.01
RN Case Manager
Odyssey Hospice
2010.01 - 2012.01
Staff Registered Nurse
Glenshire Nursing and Rehab Centre
2009.01 - 2010.01
Staff Nurse
Provena St Mary Hospital
2009.01 - 2009.01
Bachelor of Science Nursing - Nursing
American Sentinel University
Certified Case Manager -
Commission For Case Management
Similar Profiles
JUDITH RUIZ-BRANCHJUDITH RUIZ-BRANCH
Director of External Affairs at Illinois Association Of Medicaid Health PlansDirector of External Affairs at Illinois Association Of Medicaid Health Plans
Aviyah IsraelAviyah Israel
Customer Service Representative (Remote) at Automated Health Systems Inc. (Ohio Medicaid)Customer Service Representative (Remote) at Automated Health Systems Inc. (Ohio Medicaid)
Lauren StokesLauren Stokes
UM, Medicaid Post-Acute Team Lead at Aetna Better Health Medicaid Centralized TeamUM, Medicaid Post-Acute Team Lead at Aetna Better Health Medicaid Centralized Team