Dr.Rukiyar Marty
Wesley Chapel,FL
Summary
Accomplished healthcare executive with a proven track record at Ensemble, adept in regulatory compliance and team leadership. Excelled in enhancing operational efficiency and achieving 5-star HEDIS/CAHPS ratings through strategic planning and effective staff development. Skilled in financial management and adept at fostering collaborative environments to improve patient care outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Virtual Utilization Review Nurse
Ensemble
11.2023 - Current
- Reviewing patient medical records and treatment plans to determine the medical necessity and appropriateness of healthcare services provided
- Conducting utilization reviews remotely through virtual platforms to assess the efficiency and quality of healthcare services delivered to patients
- Collaborating with healthcare providers, insurance companies, and other stakeholders to ensure that services are delivered in accordance with established guidelines and standards
- Evaluating the utilization of healthcare resources to identify opportunities for improvement and cost containment
- Communicating with healthcare providers to gather additional information or clarification regarding treatment plans and medical records
- Making recommendations for changes in treatment plans, services, or care settings based on the findings of utilization reviews
- Documenting review findings, decisions, and recommendations in accordance with regulatory requirements and organizational policies
- Participating in case conferences and multidisciplinary team meetings to discuss complex cases and develop care plans
- Staying current on industry trends, regulations, and best practices related to utilization review and case management
Compliance Auditor
Broad Step
08.2023 - 11.2023
- Reviewing and analyzing company policies, procedures, and practices to ensure they comply with relevant laws and regulations
- Conducting audits and inspections to identify areas of non-compliance or areas where improvements can be made
- Developing and implementing audit plans and programs to assess compliance with internal policies and external regulations
- Investigating complaints or reports of non-compliance and taking appropriate action to address issues
- Documenting audit findings, preparing reports, and making recommendations for corrective action
- Communicating with management and stakeholders about compliance issues and providing guidance on how to achieve and maintain compliance
- Monitoring changes in laws and regulations that may affect the organization's compliance requirements
- Providing training and education to employees on compliance-related matters
- Collaborating with other departments, such as legal and human resources, to ensure a comprehensive approach to compliance
- Overall, the role of a compliance auditor is crucial in helping organizations ensure that they operate within the boundaries of applicable laws, regulations, and internal policies to maintain ethical practices and minimize risks
Director of Clinical Operations
Greenbrook Medical
01.2023 - 08.2023
- Oversee the operations and clinical functionality of four primary care offices
- Manage office budgets, inventory, and supplies
- Ensure compliance with industry regulations and standards
- Develop and implement processes and procedures to enhance office efficiency and productivity
- Monitor and measure office performance metrics to ensure the provision of high-quality care
- Evaluate and recommend improvements to the patient experience
- Work collaboratively with cross-functional teams to improve patient care and achieve business goals
- Provide training and development opportunities to clinical staff
- Collaborate with the finance team to manage office budgets and forecast business growth
- Developed and implemented strategic and tactical operating plans while focusing on HEDIS/CAHPS to achieve 5-star ratings for all locations
Practice Administrator
Immediate Medcare and Family Doctors
01.2018 - 01.2023
- Lead administration and operations for group of 3 primary care practices job responsibilities include:
- Recruit and Oversee Staff, provider credentialing and assist with onboarding and training them
- Assign activities, offer feedback and developmental training, and conduct performance reviews
- Handle the Facility’s Finances
- Financial manager and accounting developing and following budgets
- Processing payroll, creating financial reports measuring cash flow and profitability, handling invoices and checks, and coordinating with insurance
- Lead Improvement Activities
- Work with staff and outside agencies such as government bodies and insurance companies to improve how our facility delivers healthcare services
- This includes improving quality issues, decreasing wait times for patients, and creating long term plans to grow the facility’s profits and patient capacity
- Perform General Administrative Tasks
- Making work schedules, manage records, order supplies, attend meetings, contact insurance companies and patients, and perform other general administrative tasks as needed
- Monitor for Regulatory Compliance
- Understanding state and federal laws and regulations regarding patient care and healthcare facility management is an important part of the job
- Practice Monitoring for compliance, coordinate with outside parties, and address any compliance issues promptly
- Developed and implemented strategic and tactical operating plans while focusing on HEDIS/CAHPS to achieve 5-star ratings for all locations
Care Manager
Davita Medical Group
01.2016 - 01.2018
- Assessed, planned, and coordinated all aspects of kidney care services across the continuum of care for patients across 10 locations
- Acted as patient advocate and facilitated patient/family education regarding treatment options
- Reviewed patient charts, coordinating care and reviewing case progress to optimize clinical outcomes
- Partnered with social services and government agencies, making patient referrals to community resources and removing barriers to care
Utilization Review Nurse
Conifer
01.2014 - 01.2018
- Conducted pre-authorization and appropriateness of treatment reviews using evidence-based guidelines and criteria
- Escalated cases to reviewing physician as needed when medical necessity criteria not met
- Negotiated service rates with out-of-network providers, utilizing standard reimbursement methodologies
- Identified cases for potential disease and/or case management, referring to appropriate department for follow-up
Education
Doctorate of Healthcare Administration -
Virginia Lynchburg University
12.2023
Masters in Public Health Administration -
Southern New Hampshire University
12.2022
Bachelor in Health Care Administration -
Pasco Hernando State College
12.2019
Skills
- Business Operations
- Financial Management
- Regulatory Compliance
- Budget Administration
- Recruiting & Staffing Initiatives
- Contract Negotiations
- Team Building & Leadership
- Technology Savvy
- Staff Development
- Healthcare Facility Management
- Medicare Advantage Proficient
- Milliman guidelines
- Physician consultations
- Documentation and reporting
- Compliance procedures
- Communication
- Clinical assessment
- Healthcare regulations
- Prior authorization
- Managed care
Certification
LPN with compact agreement, Florida
Timeline
Virtual Utilization Review Nurse
Ensemble
11.2023 - Current
Compliance Auditor
Broad Step
08.2023 - 11.2023
Director of Clinical Operations
Greenbrook Medical
01.2023 - 08.2023
Practice Administrator
Immediate Medcare and Family Doctors
01.2018 - 01.2023
Care Manager
Davita Medical Group
01.2016 - 01.2018
Utilization Review Nurse
Conifer
01.2014 - 01.2018
Doctorate of Healthcare Administration -
Virginia Lynchburg University
Masters in Public Health Administration -
Southern New Hampshire University
Bachelor in Health Care Administration -
Pasco Hernando State College
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