Cassandra Francois

Conduct appeal review of denied services through the evaluation of medical documents submitted by various providers of service in order to determine the medical necessity of inpatient admissions, inpatient and outpatient procedures, home health services, durable medical equipment, and high tech imaging studies.

Conduct retrospective claims reviews for emergency room visits and office procedures.

Provide training and preceptorship to new Appeal nurses.

Serve as a resource and working closely with non-clinical appeals staff.

Work closely with BlueCare Medical Directors to reach the best and most appropriate outcome for appealed services.

Review and summarize all medical documents received for clinical review to determine the medical necessity of the requested care.

Utilize clinical guidelines and experience

Facilitate review and provide recommendations if additional Medical Director review is required for appeal resolution.

Collaborate with various provider offices in order to obtain the necessary and appropriate documents for a thorough appeal review, resolution, and best outcome.

Utilize Microsoft word, Outlook, Facets, CareAdvance, ACTS, Excel to conduct research, documentation, and communication of various job related tasks.

Proficient in the use of MCG guidelines, Cohere guidelines, TennCare Rules, and CMS LCD/NCD to conduct clinical reviews.

Knowledgeable in NCQA, URAC, and EQRO

Provide direct patient care to pediatric patients with mental health diagnosis.

Provide patient and family education regarding disease process and medications.

Assist and work closely with the treatment team to develop an appropriate plan of care.

Schedule daily patient activities and staff assignments and responsibilities.

Coordinate admissions and perform assessments for new patients. Assess, monitor, and manage medical conditions. Perform lab draws and prepare specimens for lab pickup, perform EKG exams, and assist physical exams.

Orient and train new employees.

Perform clinical assessment to identify gaps in care and opportunities for case management intervention.

Coordinate patient benefits through patient education of available benefits.

Assure patient needs are met upon hospital discharge through outreach phone calls to confirm necessary services are in place and provide assistance as needed.

Provide patient education on their disease processes affecting their health, and medications

Provide information and assistance with identifying community resources.

Utilize Milliman Care Guidelines and Healthwise Knowledge Base.

Utilize ICMS system to maintain patient information.

Perform medical record audits at physician offices looking for completed STAR/HEDIS measures and verifying disease processes.

Work closely with physicians and office staff to identify patients needing attention to STAR/HEDIS measures, , patients needing a face to face visit, and coordination of care as needed.

Maintain information and enter data into Cigna-HealthSpring's system of record.

Manage daily workflow to allow rotation to assigned physician offices for chart audits and prompting for next visit.

Perform calls to patients to assess case management needs, provide education, and assist with scheduling physician office visits or preventive care screenings as needed.

Responsible for working with healthcare providers to optimize patient benefits and promote effective use of benefits.

Assess medical necessity for inpatient and outpatient services to include surgical and diagnostic procedures, home health services, durable medical equipment; physical, occupational, and speech therapy services.

Coordinate appeals for denied services.

Conduct precertification ane retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts.

Serve as preceptor to new employees and as a resource to new and existing employees.

Responsible for telephonic review of clinical information to assess the appropriateness of inpatient and outpatient medical services and inpatient psychiatric admissions.

Preceptor to new employees. Serve as a resource to coworkers.

Assist case managers with discharge planning, coordinate small durable medical equipment, negotiate rates with DME providers, monitor patient progress at home, and assess patients for new or potential case management needs.

Promoted to Referral Analyst responsible for reviewing the appropriateness of case management referrals, outreach to participants and hospital personnel to initial discharge planning. Provide patient, family, and provider education.

Direct patient care of adult patients with chemical dependency and mental health diagnoses.

Coordinate admissions and assessments of new patients.

Ongoing monitoring of physical and emotional status of patients.

Coordinate with treatment team to develop an appropriate plan of care and provided education to patients.

Monitor patients for withdrawal symptoms and provide appropriate care.

Assist with physical exam and perform lab draws.

Provide direct patient care and serve as shift charge nurse for pediatric patients with mental health diagnoses.

Provide patient and family education.

Assist and work close with treatment team to develop treatment plans.

Schedule daily activities, staffing assignments, assist with physical exam, perform lab draws, and schedule and perform diagnostic procedures.

Orient and train new employees, coordinate new admissions, and complete initial assessments.

Provide pre and post operative care for surgical patients.

Provide care for patients with cardiac issues, respiratory issues, and diabetes.

Provide patient education and discharge planning.

Responsible for patient direct patient care to in the form of conducting assessments; vital sign, blood glucose and cardiac monitoring, medication administration, patient centered treatments, formulate nursing care plans, and transcribe physician orders.