Candice Germany

Key responsibilities of an RN Analyst include:

• Level of Care Review (LOCERI) Support: Providing secondary or higher-level reviews, data collection, data entry, and communication with providers. Performs in depth case review LOCERI case to determine medical eligibility of vulnerable members of our population for Medicaid funded Long-term Services and Supports (LTSS).
• Provider Training and Education: Training MCOs and FFS providers on LOCERI procedures and requirements.
• Appeal Representation: Representing department in appeals related to LOCERI decisions.
• Data Analysis and Reporting: Collecting, analyzing, and interpreting data related to LOCERI to support decision-making and policy development.
• Stakeholder Communication: Collaborating with various stakeholders, including healthcare providers, program administrators, and state/federal agencies.
• Policy Interpretation and Application: Applying rules, regulations, and laws to the administration of programs, implementing corrective actions, and rendering decisions on unusual policy interpretation issues.

• Self-directed independent nurse care management consultant specializing in managed care case management and utilization review for Medicaid and Medicare members.
• Performing in-depth review of organizations operations practices, policies, procedures, clinical training, onboarding, and billing practices for case management services.
• Provided subject matter expertise in case management for the purposes of program development and organizational growth.
• Develop plan for implementation of new operational documentation systems for case management in both managed care and home care.
• Develop comprehensive onboarding and training programs for clinical staff.
• Provide strategies for recruitment and retention for case managers.
• Provided comprehensive knowledge of process improvement related to STAR measures and HEDIS.
• Provided recommendations for request for proposal, grant, or program submissions within the government sector.

• Contracted to focused on design and implementation of a new virtual monitoring and nursing program.
• Created all new policy and process.
• Developed education and core competencies for a team of unlicensed personal care technicians to monitor patients virtually using a high tech 2-way camera.
• Provided clinical oversight of program.
• Responsible for quality and 24/7 visibility to team and oversight safety of patients admitted within program.
• Responsible for cost center budgeted over-time.
• Led staff meetings to keep team informed of departmental changes and provide opportunities for nurses to share ideas and concerns.
• Trained new staff in proper techniques, care standards, operational procedures, and safety protocols.
• Served as a key point of contact between nursing staff, physicians, administration, and other healthcare professionals.
• Investigated and independently resolved complaints from staff, physicians, and patients by leveraging clinical judgment and unit management expertise.

• 4-month contract addressing the 2024 DNSP enrollment for Humana Health Plan - HRA Campaign
• Led a team of 22 nurses to provide case management services to Medicare DSNP population across all compact states, MI, NY, PR.
• Providing clinical oversight of staff and functions to meet organizational goals in case management and utilization of benefits and services.
• Responsible for providing expert knowledge of enrollment, case management continuum, telephonic assessment and screening processes, referrals, and remediation of barriers related to SODH needs.
• Works with the leadership team, PCP, the member, and assigned case management RN to promote the delivery of quality services at the most appropriate and cost-effective setting.
• Performs as the member advocate with emphasis on education regarding managed care, disease management and PCP treatment plans.
• Monitors member's utilization patterns for identification of high risk, and under and overuse of services.
• Collaborates with case management RN Team, Medical Director, and senior management on complex cases.
• Assists where necessary or through project management for those business ventures undertaken by the Company to ensure its profitable future.

• Reports to the Chief Executive Officer.
• Leads a team of 85+ employees over multiple service lines.
• Responsible for operational and strategic and financial leadership of adult severe mental illness & life choices (children's and I/DD) case management, central patient access & scheduling, customer service call center, entitlement services, guardianship services coordination, and art therapy services.
• Creates an environment that creates and supports innovation and risk taking to achieve set performance measures and organization vision.
• Solicits, writes, and manages total grant process applying for up to 450K in grant funding and dedicates Wellbeing case management staff to provide the most appropriate utilization of resources related to grants.
• Submits RFPs for new programming and creates program descriptions.
• Actively monitors and sources new revenue generating opportunities, reduce waste, develops performance metrics to align with NSOs strategic goals.
• Drives continuous quality improvement, maintains an active knowledge of the healthcare trends and ecosystem.
• Collaborates with local Detroit Metro area key players such as Detroit Area Agency on Aging, Detroit Wayne Health Network, City of Detroit, and Wayne University Health.

• Interim Contracted leader.
• Maintained the image of the care center in the community, as well as state and national organizations.
• Drive compliance with CMS regulations for conditions of participation.
• Survey readiness and preparation.
• Maintenance of HHCAP continuous improvement projects.
• Provides leadership to an entire team of over 300 clinicians including RN clinical managers, field staff consisting of RNs, LPNs, Therapy team and HHAs.
• Provides oversight a dynamic interdisciplinary team to ensure compliance and excellent patient care.
• Monitors and evaluates employee performance for over 200 staff.
• Holds employees accountable for the attainment of organizational goals.
• Key responsibilities involve budgetary, performance management, providing clinical direction, ensuring compliant growth and profitability of the agency, delivering positive results to achieve quality care and member satisfaction, productivity metrics, and reducing the overall cost of care to effectively achieve organizational goals.
• Ensures the enhancement of business development, and continuous improvement of care center efficiency and fiscal success.
• Participates in activities associated with the management of workplace health and safety.
• Identifies and reports health and safety risks, accidents, incidents, injuries, and property damage at the workplace.

• Focused on HEDIS measures and managed quality program for Maternal Infant Health, Immunizations, Breast Cancer, and Colorectal Screening.
• Accounted for quality improvement measures for Hepatitis C, State compliance submissions and Value Based Care.
• Responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion.
• Plan and directed outreach schedules for member material and HEDIS calls as well as project budgets.
• Monitors the project from inception through delivery.
• May engaged and oversaw the work of external vendors for the purpose of data and survey collection.
• Assigned, directed, and monitored system analysis and program staff.
• Focused on process improvement, organizational change management, program management and other processes relative to the business.
• Remote

• Company Overview: Remote (Transfer from Anthem)
• Lead 4 specialty teams (55 FTEs) servicing several large group accounts within the automotive and industrial industry.
• Lead oversight of 2 onsite audits from third party consulting groups such as Willis Towers Watson and Mercer Health Administration.
• Focused on successfully implementing a new program centered on concierge call line and light touch case management.
• Lead a team focused on high dollar claims review and recovery.
• While in this role, this team recovered and certified savings of upwards of 1 million dollars.
• Motivated staff to produce beyond goal.
• Oversight of several projects including developing a quality tool for the high dollar team and review of policies focused on our integrated specialty program and care team.
• Reviewed gaps in policies for TCPA, NCQA within my specialty team and worked to correct such.
• Remote (Transfer from Anthem)

• Corporate Health Services Director - Worked across lines of business working in Medicare, Medicaid, and Commercial lines of business as subject matter expert for case management programs in complex, post discharge, and care coordination.
• Completed internal deep dive audits for 35 health plans to assess compliance with corporate metrics and operational standards.
• Assisted in the development and implementation of corporate policies and procedures for case management.
• Utilized work force management data to identify inefficiencies in health plan management strategies addressing associate productivity and time management.
• Ensured plans adhered to NCQA, HEDIS, compliance and TCPA standards.
• Helped to identify gaps in process, deviations from federal compliance standards perpetuating high-level risk to the plan and provided solutions for mitigating such risks.
• Utilized reporting data to support audit findings.
• Played a key contributor role in setting direction and participating in developing new case management programs.
• Key contributor in developing strategies to meet overall key performance indicators for documentation improvement, care plan automation, and case mix metrics.
• Finalized projects with a detailed report in an executive summary via WebEx, power point, or word to senior leadership.
• Provided health plan support with hiring, training and development as needed.
• Provided consulting in performance management and coaching of direct reports as needed to health plan as needed.
• ALL REMOTE

• Utilization management for skilled nursing facilities, acute rehab, home care, LTACH and inpatient acute care.
• Focused case manager and lead for high dollar cases, high dollar skilled nurse facility or home-based drug, durable medical and nutritional therapy negotiations payable at a reduced percent of Medicare's U/C rate.
• Lead clinical nurse for Piloted SNF to Home transition of Care Program producing a 25% decrease in readmissions of orthopedic surgical cases related to pain, falls and infection.
• Community Outreach and Lead Nurse for skilled nursing facility behavioral health admission transition of care program producing a 50% decrease in length of stay of BH related NF admissions.
• Expert in InterQual and MCG CareWeb.
• ICD 9 coding.
• Pleased to act as interim supervisor for prior authorization team from February 2011 through May 2011.
• As interim, I overall a team of 5 reports.
• Maintain deliverable deadline for auth requests, provided physician support with high dollar drug carve out negotiations, maintained production and turnaround times, subject matter expert for SNF level of care, and represented plan at State Medicaid meetings for managed care.

• Telephonic case management of children with special health care needs focused on Disease Management for Asthma and Juvenile Diabetes.
• Primary case management encompasses the entire continuum from inpatient to home.

• Telephonic case management of catastrophic injured workers cases for assigned employer management accounts.
• Managed high-profile employer groups like the City of Cleveland, Cleveland Municipal School District and Police department.
• Provided onsite wellness clinics upon request.
• Collaborated with marketing to develop employer focused clinical wellness programs to reduce the cost of care.
• Provided total case management including analysis of employer spending and pharmacy usage.
• Provided self-insured management of all medical necessity claims and requests.
• Attended Ohio worker's Compensation hearing as subpoenaed on behalf of employer representation on high dollar cases.

• Supervisor for home healthcare organization, teaching STNA classes, oversight for field staff RNs, onboarding, performance review, and competency testing.
• Responsibility for direct reports and leadership of approximately 30 RN/LPNs and upwards of 80 HHAs.

• Supervisor for home healthcare organization, oversight for field staff RN/LPNSs, onboarding, performance review, and competency testing.
• Obtained medical orders, authorizations for wavier and passport clients.
• Responsibility for direct reports and leadership of approximately 16 HHAs and 9 RN/LPNs.