Diane Atherton
Petoskey,MI
Summary
Highly motivated RN-MSN specializing in care coordination with 20+ years of experience in case management and utilization review. Demonstrate a culture of collaboration and communication, following through on details and large-scale goals while maintaining courteous, accurate, and timely relations with team members and external stakeholders. Expert in complex case management with in-depth knowledge of MSO / ACO, Managed Medicare / Medicaid, and acute and post-acute hospital care, as well as other environments. An astute professional who has demonstrated clinical proficiency in conducting thorough patient assessments and effective discharge plans. Strong leadership and administrative abilities, including program development, performance monitoring, and improvement, delegation/escalation of decisions and problems. Strong background in profit and loss analysis, Medicare / Medicaid regulations, and URAC / NCQA processes, and CMS star ratings. Passionate about value-based, patient-centered health care and has a proven record for leading and developing teams to meet the myriad of demands across the entire enterprise. Certified in Milliman Clinical guidelines and proficient in InterQual. Proficient in the use of multiple hospital EMR systems including Epix, Cerner, and Sunrise. Skilled Clinical Consultant well versed in optimizing clinical procedures and patient care by utilizing a data-driven approach. Advanced abilities in Microsoft Office, Smartsheet, SharePoint and Visio. Skilled at making measurable improvements to workflows and operations and seeking a fast-paced position.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Adjunct Clinical Instructor
North Central Michigan College
Petoskey, MI
08.2023 - Current
- Clinical Instruction at McLaren Northern Michigan Hospital. Med/Surg, ICU, CVU, ARU, ER and Same day surgery units
- Evaluated student's competency based upon laboratory simulations and clinical experiences.
- Contributed subject matter expertise toward improving overall training program and skills displayed by student nurses.
- Instructed courses in nursing to meet educational requirements stated in credit course outline and board of registered nursing regulations.
- Remained current in instructional methods and evidence-based, best practice nursing concepts and impact such concepts place on nursing program students' education.
- Procured knowledge of national and local trends in nursing practices to successfully integrate into learning activities.
- Observed and evaluated student performance in meeting course objectives and student learning outcomes through assignments, projects and examinations.
- Cultivated collaborative and innovative learning environment to meet each student's unique educational needs.
- Worked with students to ensure comprehensive success.
Clinical Program Consultant Project Manager
WELLMED MEDICAL MANAGEMENT
03.2022 - Current
- Manage scoping, planning and implementation of key clinical initiatives, reporting outcomes to leadership
- Develop and maintain detailed project plans (including resource assignments, schedules, dependencies, etc.)
- Use a process driven approach to identify root cause and process improvement opportunities
- Collect information, input, data, and subject matter expertise relevant to identifying best practices
- Conduct analysis of data, metrics, information, and reports (e.g., productivity metrics, outcomes)
- Evaluate processes and outcomes against benchmarks and metrics and identify potential business impacts of current state
- Create overall program/process framework based on research (e.g., purpose, mission, goals, and objectives)
- Create and automate detailed clinical and business level reports / dashboards
- Maintain databases of projects, programs, and ongoing activities supporting Clinical Policy
- Actively sought out feedback from stakeholders throughout the duration of a project in order to identify areas needing improvement or adjustment.
- Conducted regular status meetings with internal teams and external partners to track progress against established milestones.
- Participated in cross-functional teams responsible for developing innovative solutions for complex problems.
- Ensured that all regulatory requirements were met prior to implementation of any program changes.
Clinical Instructor
Herzing University
05.2022 - 12.2022
- Provide Orientation for new students at the healthcare facility, including the facility's job description for Nursing staff, the Policy and Procedure Manual, location of educational resources, safety precautions, emergency protocols and blood-borne pathogens protection
- Assign students to a variety of medical departments/procedures to gain experience in the role of the Nurse (Licensed Practical or Registered Nurses)
- Promote a positive learning environment with emphasis on patient/student safety and compliance that meets national accrediting agency standards
- Exhibit professional behavior and communication that serves as a positive role model for students Complete weekly clinical evaluations with systematic observations, and timely objective/subjective feedback to the student
- Provide feedback to the Dean of Nursing about current department/hospital policies or changes in practice in the nursing field, and recommend appropriate program changes
- Maintain current state-of-the-art knowledge and skills through continuing education and professional development opportunities Perform supervisory and other duties as assigned by the Dean or other designee.
Manager
WELLMED MEDICAL MANAGEMENT
08.2016 - 03.2022
- Provide expert inpatient and outpatient complex case management, Utilization review, transition of care, and concurrent review for acute and long-term care hospitals and skilled nursing facilities Lead and supervise a team of 10+ nurses, social workers, and clerical staff
- Actively prevent readmissions and reduce stay lengths by providing guidance and training physicians and case managers Manage all long-stay / catastrophic cases
- Direct and supervise all transitional care and continued stay operations
- Lead all on-site collaboration with hospital case management for inpatient and post-acute settings Develop and implement policies and procedures to ensure continued compliance with all applicable regulatory and accreditation standards, including NCQA, URAC, and state and federal standards
- Facilitate daily interdisciplinary team conferences (IDTCs) to promote coordination and communication
- Organize quarterly JOCs with high-volume hospitals to lead discussions around utilization, transition of care, and utilization
- Draft and continuously update all SOPs, job descriptions, and policies
- Monitor and analyze weekly observation cases, readmission tracking and trending, and other reports to determine performance and identify areas in need of improvement
- Oversee all utilization, diagnosis-related groups (DRGs), outliers, and denials.
- Recruited and hired qualified candidates to fill open positions.
Supervisor, Clinical Care
WELLCARE HEALTH PLANS
Orlando
08.2007 - 02.2017
- Set specific goals for projects to measure progress and evaluate end results.
- Evaluated needs of departments and delegated tasks to optimize overall production.
- Created new strategies for improving customer service standards within the organization.
- Resolved customer complaints and adjusted policies to meet changing needs.
- Monitored employee productivity to provide constructive feedback and coaching.
- Analyzed company's expenditures and developed financial models.
- Implemented cost-cutting measures without compromising quality of services offered.
- Maintained operating schedules to provide effective coverage for key areas and achieve objectives.
- Interviewed applicants, recommended individuals for hiring and evaluated staff performance.
- Resolved customer complaints in a timely manner while ensuring customer satisfaction.
Concurrent Review Nurse
Managed Medicaid, Insurance
02.2016 - 07.2016
- Identified opportunities for improvement in health plan operations through analysis of utilization trends and outcomes.
- Interpreted clinical data from medical records and applied evidence-based criteria in order to make decisions regarding the appropriateness of care provided.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
Instructor
Orange County Public Schools
Winter Park, FL
08.2007 - 03.2015
- CNA, HHA classrom instructor
- Certified BLS instructor
- Taught CEU courses ie: HIV Domestic Violence, Med Compliance
- Created lesson plans and chose supporting materials to promote positive learning experiences.
- Observed and evaluated student performance and development and provided appropriate feedback on work.
- Engaged students through lecture and discussion, increasing classroom interaction to build inclusive learning environment.
Field Case Manager
CorVel Risk Management
01.2006 - 07.2007
Telephonic Case Manager
Genex Corporation
09.2004 - 12.2005
Education
Master of Science in Nursing, Population Health & Care Coordination -
Capella University
Online Leraning06.2021
Associate of Science in Nursing -
St. Petersburg College
St. Petersburg, FL01.1995
Skills
- Transition of Care
- P&L, KPI's
- Accountability
- MSO / ACO
- CAHPS / HOS
- Discharge Planning
- Performance Management
- Program Direction & Administration
- Complex Case Management
- URAC / NCQA Processes
- Managed Medicare / Medicaid
- Medicare & Medicaid Regulations
- Training & Education
- Regulatory Compliance
- Utilization Review
- CMS Star Ratings
- Acute & Post-Acute Hospital Care
- Accreditation Initiatives
- Quality Metrics & Improvement
- Customer Care
- Evidence-Based Methods
- Collecting Data
- Updating Processes
- Improving Facility Workflows
- Clinical Best Practices
- Active Listening
- Microsoft Office
- Planning & Organizing
- Critical Thinking
- Data Management
- Relationship Building
- Friendly, Positive Attitude
- Organizational Skills
- Computer Skills
- Conflict Resolution
- Team Management
Certification
- Certified Case Manager, Commission for Case Manager Certification (CCMC), 4209127
- Multi-State Nursing License, RN3413972, 5/2025
- Michigan Nursing License, 4704402197, 5/2025
- American Heart BLS, 215415361702
- Six Sigma Green Belt Certified, 66179448
- Medicare & Retirement Professional Certification
Organizations
- United Health Group Emerging Leaders Program 2022 Alumni
- United Health Group Center for Clinician Advancement Member
- United Health Care Children's Foundation Ambassador
- WellMed Social Responsibility Council Member
References
References available upon request.
Timeline
Adjunct Clinical Instructor
North Central Michigan College
08.2023 - Current
Clinical Instructor
Herzing University
05.2022 - 12.2022
Clinical Program Consultant Project Manager
WELLMED MEDICAL MANAGEMENT
03.2022 - Current
Manager
WELLMED MEDICAL MANAGEMENT
08.2016 - 03.2022
Concurrent Review Nurse
Managed Medicaid, Insurance
02.2016 - 07.2016
Supervisor, Clinical Care
WELLCARE HEALTH PLANS
08.2007 - 02.2017
Instructor
Orange County Public Schools
08.2007 - 03.2015
Field Case Manager
CorVel Risk Management
01.2006 - 07.2007
Telephonic Case Manager
Genex Corporation
09.2004 - 12.2005
Master of Science in Nursing, Population Health & Care Coordination -
Capella University
Associate of Science in Nursing -
St. Petersburg College
- Certified Case Manager, Commission for Case Manager Certification (CCMC), 4209127
- Multi-State Nursing License, RN3413972, 5/2025
- Michigan Nursing License, 4704402197, 5/2025
- American Heart BLS, 215415361702
- Six Sigma Green Belt Certified, 66179448
- Medicare & Retirement Professional Certification
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