Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

DuVeen V. Blaye

TEMPE,AZ

Summary

Registered Nurse with extensive experience in managed care. Knowledgeable in quality reviews, case management, discharge planning, and medical benefit review. Highly skilled in team building, counseling, administration and mediation. Proven leadership in delivery and improving holistic care. Able to use collaborative strategies with patient’s family members, significant others and members of the interdisciplinary team. An expressive, versatile individual who is highly responsible with excellent communication skills.

Overview

45
45
years of professional experience
1
1
Certification

Work History

Transitional Care Manager

Honor Health
06.2018 - Current
  • Improve patient safety and quality outcomes through reduced patient readmission.
  • Collaborate with patients / caregivers early prior to and post discharge. Ensure PCP follow up within 7-14 days post discharge.
  • Assess readmission risk and barriers to outpatient care, including home support, medication management, returning the patient to their PCP or specialty physician, and when to recognize signs of trouble, and when to call 911.
  • Prevent breakdown of one of the readmission risk or some breakdown in the care.
  • Recognize the risk with older adults with multiple chronic conditions and complex therapeutic regimens.
  • Avert poor handoffs of these older adults, and their family caregivers from hospital to home.
  • Recognize sentinel events that can cause readmissions, multiple Chronic Conditions.
  • Learning deficits, Educational Needs, Care Plan reinforcement.
  • Multiple Specialist; the need for Care Coordination, Poly Pharmacy / medication noncompliance concerns.
  • Complicated Discharge needs.
  • Lifestyle and Wellness support, Disease or Condition Management.
  • More than 2 ED visits

Case Management Supervisor

TriWest Healthcare Alliance
04.2017 - 06.2018
  • The Case Management Supervisor provides daily operations leadership for case management services and staff to ensure high service levels and delivery of quality and timely Case management services.
  • Hires, trains, coaches, counsels, and develops clinical and non-clinical staff.
  • Applies knowledge of HIPPA privacy and security regulations as well as URAC accreditation standards to ensure compliance in daily practice.
  • Coordinates staff orientation and training.
  • Ensures staff provides case management within scope of practice and in compliance with organizational protocols, Desk Procedures and Policies.
  • Collaborates with the Training Department to provide staff training, including participation in the development of training aids.
  • Documents and assesses effectiveness of staff training.
  • Supervises individual staff caseload and Veteran treatment plans to ensure delivery of care, productivity and timeliness.
  • Evaluates case manager practice for quality, timeliness, and process consistency.
  • Conducts regular and ad hoc review audits, providing staff feedback regarding results and process improvement.
  • Participates in the evaluation of the case management program.
  • Collaborates with medical providers, the Case Management Director and Medical Directors on program interpretation and guidance.
  • Participates in clinical and non-clinical performance improvement projects designed to retain URAC accreditation.
  • Actively participates in teleconferences and meetings.
  • Performed project management oversight of the Veteran Administration In-Vitro Fertilization Program implementation.
  • Wrote the algorithm process for the Veterans Administration In-Vitro Fertilization at TriWest Healthcare Alliance.

Case Manager

St. Luke’s Hospital
04.2016 - 09.2016
  • Responsible for documentation of appropriate medical necessity for the inpatient or observation status.
  • Responsible for proper status and tier level of care assignments.
  • Facilitate other allied health professionals (OT, PT, etc.) to promote and ensure that quality Care is provided and outcomes are achieved in a timely and cost effective manner.
  • Transition patients to various levels of care.
  • Provide effective communication of clinical information and plan of care between the Hospitals, Emergency Room Physician and Specialist, as well as other key healthcare providers involved in the case.

Case Manager

Dignity Health
04.2013 - 02.2016
  • Manages individual patients across the health care continuum to achieve the optimal clinical, financial, operational, and satisfaction outcomes.
  • Acts in a leadership function with process improvement activities for populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes.
  • Acts in a leadership function to collaboratively develop and manage the interdisciplinary patient discharge plan.
  • Effectively communicates the plan across the continuum of care.
  • Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes.
  • Assesses patient admissions and continued stay utilizing standard criteria.
  • Identifies issues that may delay patient discharge and facilitates resolution of these issues.
  • Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team.
  • Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements.
  • Educates internal members of the health care team on case management and managed care concepts.
  • Facilitates integration of concepts into daily practice.
  • May supervise other staff.

Outpatient Care Manager

Advocate Health Care
05.2012 - 03.2013
  • Company Overview: (An ACO)
  • Conducts outreach and introductory calls with members to explain the program and encourage participation for eligible members.
  • Completes designated assessment of patient via telephone.
  • May require multiple conversations with patient and family.
  • Obtains information about the patient’s condition from physicians, patients, caregivers and other providers.
  • Develops a care plan that reflects the clinical progression and includes frequency of contact, medication and clinical education, symptom control, anticipatory guidance, care coordination and completion of advanced care plan documents.
  • Secures agreement for plan with physician, patient and caregiver.
  • Executes care plan follow-up conversations with patient, family, physician and other providers with frequency determined by the patient’s acuity.
  • Evaluates impact of plan and ability of plan to meet patient goals, and revises plan as necessary.
  • Completes documentation according to program policies and procedures.
  • Manages a group of patients at various levels of acuity and with varied care plans; assures plan goals are met on time.
  • Proficient use of Active Advice, E-care, and Cerner works.

Case Manager

Professional Dynamic Network
08.2010 - 04.2012
  • Temporary Staffing for Price Waterhouse Coopers @ Stroger Hospital of Cook County.
  • Duties include:
  • Maximizing client revenue by reviewing medical bills from a nurse perspective, including appropriate billing, coding and treatment, fee schedule compliance, over-utilization and erroneous charges.
  • Retrospective review of Observation cases, and Inpatient cases for appropriateness of observation status, and inpatient status using Interqual level of care criteria.
  • Performed Stroger Hospital Case management process, to participate in restructuring of the case management process with Price Waterhouse Coopers.
  • Collaborate with inpatient staff, and physicians to determine goals for length of stay management and discharge management activities.
  • Proficient in the use of Cerner medical record, Power Chart.

Case Manager

Managed Care Staffers
02.2010 - 06.2010
  • Temporary staffing for hospitals performing case management.
  • Review admissions and ongoing stays of patients with respect to the medical necessity, appropriateness, and quality of care.
  • Performs concurrent review process.
  • Worked with physicians and Medical Director regarding case issues and concurrent denials as indicated.
  • Applied pathways/guidelines, assesses variances, and purposes interventions as indicated.
  • Participates in the development, implementations and evaluation of pathway / guidelines and process improvement plans.
  • Functioned as an expert clinical practitioner within the Case Management team and served as a resource to assigned units.
  • Proficient in the use of Midas medical record.

Case Manager

Neurologic & Orthopedic Hospital of Chicago
02.2008 - 09.2009
  • Monitors the plan of care in collaboration with the patient care team; provided leadership and guidance to the care team in individualizing and implementing the plan of care.
  • Represents the hospital in collaboration with the patients, family, the Care Team and Interdisciplinary Care Team to assure appropriate safe, cost effective, timely and efficient care.
  • Identifies patient and family needs and arranged for consultation with specialty services needed, including, but not limited to, medical, psychosocial, financial, environmental, procurement of services and discharge planning.
  • Serves as an advocate on behalf of patients and families.
  • Communicate with patients to ensure understanding of third party payer guidelines.
  • Assures completion of all discharge related functions on a timely basis.
  • Acts as a liaison to external care providers and community health resources, coordinates patient care conferences, and assures patient and family educational needs are met.
  • On concurrent basis, assesses the appropriateness of the level of care, diagnostic time frames to determine suitability of level of care in accordance with established criteria.

Clinical Advisor

Humana Health Care Plans
09.2006 - 06.2007
  • Provide Case Management / Utilization services in targeted Markets.
  • Attend grand rounds in Market office monthly, meeting with physician advisor.
  • Act as a clinical liaison to identify, gather and act upon issues that influence efficient utilization Of services, such as network adequacy and provider contract compliance.
  • Attend team huddles to share information regarding the department; provide case review of difficult cases.
  • Perform as a clinical liaison to identify, gather and act upon issues that influence efficient utilization of services.
  • Use appropriate screening tools for referral to Disease Case Management.
  • Interact with IPA, PHO.s and MSO’s to develop a treatment plan for members with chronic hospitalizations.
  • Knowledgeable on the use of InterQual Healthcare Management Guidelines.
  • Proficient in the use of Clinical Care Advance, and CAS information systems.
  • Work from home office setting.

Case Manager

Holy Cross Hospital
09.2004 - 03.2006
  • Review admissions and extended stays of all patients in accordance with the department’s policies and procedures reviewing criteria for continued hospitalization and improving the overall quality and completeness of clinical documentation through review and interaction with clinical staff.
  • Demonstrate the ability to assess and provide appropriate planning and services for all age groups.
  • Discharge plans and screening documented in the patient’s medical record in accordance with the time frames established by the department.
  • Perform on-site concurrent reviews
  • Performed retrospective insurance reviews as requested.
  • Demonstrate knowledge of DRG based payer issues and document requirements.
  • Effectively engage home health care and durable medical equipment for patients.
  • Actively participated in the length of stay meetings and provided input into the discharge plans of difficult patients.
  • Demonstrate analytical abilities.
  • Maintain current CPR certification.

Patient Care Coordinator

University of Illinois Medical Center
12.2000 - 10.2001
  • Evaluated hospital admissions as to the medical necessity of patients for the prescribed care.
  • Monitored and evaluated the patients’ length of stay in the hospital.
  • Worked with hospital staff to assure timely discharge planning, and compliance with patient care criteria.
  • Consulted with other healthcare professionals to formulate a collaborative plan of care.
  • Prepared statistical records, reports, and case forms as required.
  • Supervised subordinates in an assigned area.
  • Educated colleagues and students, and served as a preceptor and mentor.
  • Participates in teaching activities for supportive personnel in learning activities and skill enhancement.
  • Used group process to identify, analyze and resolve care problems.
  • Initiated and participated in formal in-services; and informally as a resource person sharing knowledge with colleagues and students.
  • Practiced in a nondiscriminatory manner and is sensitive to diversity.
  • Provided accurate information to patients and other staff when ethical issues arose.
  • Assumed responsibility, and accountability for all professional decisions, and actions.
  • Maintained confidentiality and electronic written and verbal patient / employee information.

Temporary Staff Nurse

Stat Resources, INC.
01.1996 - 12.2000
  • Temporary staffing for Humana and Advocate Healthcare corporations.
  • Performed on-site concurrent review.
  • Performed telephonic concurrent and retrospective review.
  • Managed discharge planning of in-network, and out-of-network cases; and performed Case management for those cases.
  • Prescreened and gave authorizations for appropriate inpatient & outpatient procedures.
  • Familiarity with EPIC, MSR, and IDX computer information programs, and data entry into those programs.
  • Knowledgeable with Interqual, and Milliman & Robertson Healthcare Management Guidelines.
  • Collaborate with Medical Director in reviewing practice & referral patterns.
  • Worked on HCFA audits, and consulted with physician group practices on those results.
  • Worked as lead nurse, and supervisor, in several ambulatory care settings including, women’s health, pediatrics, urology, vascular surgery, general surgery, general medicine and urgent care.
  • Provided a full range of nursing care to patients with complex care needs by utilizing the nursing process.
  • Assessed patient learning needs, developed and implemented a plan of care to meet those needs, and instructed patients and families in self care and treatment measures.

OSCR, Onsite Concurrent Review Nurse

Aetna Health Plans
01.1995 - 01.1996
  • Performed on-site concurrent and retrospective review.
  • Familiarity with HMO, PPO, EPO, and POS managed care products.
  • Provided technical and advisory support for IPA groups, PHO’s, hospital and U.R. staff and insured members.
  • Managed discharge planning for complex cases, and handled medical inquiries for review by physician advisor.
  • Familiarity with Healthline, and Comtec information programs, and data entry into those programs.
  • Maintained concurrent review status standard for data entry into Healthline and Comtec.
  • Setup, maintained, and performed office duties via a home office.
  • Knowledge of provider contracts.
  • Demonstrated positive, effective communication skills, and professional behavior, that promoted cooperation and teamwork with internal and external customers.
  • Collaborated with others as a means of effectively utilizing the group process to identify, analyze, and resolve problems affecting patient care.
  • Initiated referrals to other disciplines and or services as appropriate.

Patient Care Coordinator

Humana Health Care Plans
06.1989 - 12.1994
  • Performed on-site concurrent and retrospective review.
  • Performed telephonic review of out-of-network cases.
  • Identified and coordinated all out-of-network admissions and / or services.
  • Responsible in arranging the member to be brought back into plan.
  • Served as the liaison for the member, PCP, and Health Plan to assess for appropriate discharge transferring arrangements.
  • Management of caseload; 80 - 100 cases per month with concurrent review regarding appropriateness of treatment in an acute care setting.
  • Identifies clinical problems or issues.
  • Facilitates implementation of research based on literature as it relates to the clinical practice, problems, or issues.
  • Problem solves care delivery issues using the group process and the Interdisciplinary Team at the unit, and service level.
  • Maintained supportive relationship with peers by being flexible, and willing to cross-cover.
  • Familiarity with HCFA guidelines with regard to Medicare, and Medicaid.
  • Identified clinical problems, and issues.
  • Incorporated knowledge into critical thinking about the practice as appropriate.
  • Used knowledge to validate, or change work group practice as appropriate.

Medical Service Advisor

Blue Cross and Blue Shield of Illinois
09.1987 - 06.1989
  • Familiarity with PPO product and accounts knowledge.
  • Knowledge of AEP Healthcare Management Guidelines
  • Knowledgeable of ICD-9, and CPT coding.
  • Performed telephonic concurrent review, and maintained review status by keeping up to the standard.
  • Make timely and accurate referrals to individual benefit management and case management.
  • Provide excellent member service; able to handle 100 calls daily (standard is 30).
  • Maintained the standard for data entry into the computer’s Individual Management Program information system.
  • Identified opportunities to improve patient care through monitoring, analyzing, and evaluation of care outcomes.
  • Applied creative approaches for change in practice based on quality improvement outcomes.

Emergency Department Charge Nurse

Provident Hospital
09.1984 - 09.1987
  • Maintained a clinical proficiency in every specialty of nursing at the critical care level.
  • Applied problem solving skills on the unit leading to the improvement in patient care.
  • Directed the activities of triage, data collection, observation, intervention, referral and teaching.
  • Focus on restoring order to chaos.
  • Serve as a resource of information, whether it be clinical or legal, to co-workers in the E.D.
  • Motivate and orientate new nurses to the E.D.
  • Applied the nursing process at the team, and unit level to improve patient care.
  • Demonstrated leadership by involving others in improving patient care.
  • Administered prescribed therapies using appropriate judgment, and in accordance with established policy and procedures.
  • Demonstrated professional behavior, and good communication skills that enhanced working effectively with others.

Team Leader

South Shore Hospital
06.1982 - 09.1984
  • Management of team by organizing, and delegating duties of the team to give the highest quality of patient care.
  • Proficiency in the management of care regarding telemetry, medical-surgical, and outpatient surgery.
  • Created and implemented patient care plans, as well as discharge planning.
  • Preparation, care and discharge of outpatient surgeries.
  • Knowledge of cardiac arrhythmia, and CPR for the management of telemetry patients.
  • Completed initial assessments and re-assessments of patient condition and response to treatment and other clinical findings.
  • Initiated follow-up as needed.
  • Accurately documented in the medical record patient findings, assessments, and provided care.
  • Evaluated the practice self, and others against standards of practice and relevant regulations, and took action to improve compliance.

Staff Nurse\ Depression Research Unit

Illinois State Psychiatric Institute
06.1981 - 06.1982
  • Participated in the preliminary screening, and observation of research candidates.
  • Complied with ISPI research policy.
  • Used a body of research to validate or change work group habits.
  • Identified clinical problems and issues.
  • Facilitated implementation of research based on literature as it related to the clinical practice, problems, and issues.
  • Incorporated knowledge into critical thinking about the practice as appropriate.
  • Participated in research protocols, by consistently evaluating the milieu, and plan appropriate intervention, regarding blind studies.
  • Knowledge of behavior modification as a treatment modality.
  • Participated in multi-disciplinary team for the planning of care for individual patients.
  • Implemented nursing procedures requiring the skill of a professional nurse.
  • Carried out charge responsibilities as assigned.

Charge Nurse\ Medical-Surgical Unit

Woodlawn Hospital
06.1980 - 06.1981
  • Provided a full range of nursing care to patients with complex care needs utilizing the nursing process.
  • Completed initial assessments and re-assessments of patient condition and response to treatment and other clinical findings.
  • Initiated follow-up as needed.
  • Established patient care priorities in emergency situations (cardiac arrest, crisis, etc.).
  • Prioritized patient care needs, make staff assignments that reflect optimum use of staff.
  • Used problem-solving skills, and techniques to optimize use of resources.
  • Applied appropriate infection control precautions.
  • Demonstrated leadership in following safe work practices, appropriate for the position.
  • Promoted the hospital’s mission, vision and values.
  • Supervision of the P.M. staff, and directed activities of that watch.
  • Directed and supervised patient care at all levels on the P.M. watch
  • Transcribed and integrated physician orders into the patient care plans.

Education

Baccalaureate of Science - Health Arts

University of St. Francis
Joliet, Illinois

Associate Degree - Nursing

Olive-Harvey College
Chicago, Illinois

Skills

  • Care coordination
  • Quality improvement
  • Clinical assessments
  • Services oversight
  • Medication reconciliation
  • Discharge planning
  • Interdisciplinary collaboration
  • Clinical decision making
  • Healthcare documentation

Certification

  • Certified Case Manager
  • The Commission for Case Management
  • 00144674

Timeline

Transitional Care Manager

Honor Health
06.2018 - Current

Case Management Supervisor

TriWest Healthcare Alliance
04.2017 - 06.2018

Case Manager

St. Luke’s Hospital
04.2016 - 09.2016

Case Manager

Dignity Health
04.2013 - 02.2016

Outpatient Care Manager

Advocate Health Care
05.2012 - 03.2013

Case Manager

Professional Dynamic Network
08.2010 - 04.2012

Case Manager

Managed Care Staffers
02.2010 - 06.2010

Case Manager

Neurologic & Orthopedic Hospital of Chicago
02.2008 - 09.2009

Clinical Advisor

Humana Health Care Plans
09.2006 - 06.2007

Case Manager

Holy Cross Hospital
09.2004 - 03.2006

Patient Care Coordinator

University of Illinois Medical Center
12.2000 - 10.2001

Temporary Staff Nurse

Stat Resources, INC.
01.1996 - 12.2000

OSCR, Onsite Concurrent Review Nurse

Aetna Health Plans
01.1995 - 01.1996

Patient Care Coordinator

Humana Health Care Plans
06.1989 - 12.1994

Medical Service Advisor

Blue Cross and Blue Shield of Illinois
09.1987 - 06.1989

Emergency Department Charge Nurse

Provident Hospital
09.1984 - 09.1987

Team Leader

South Shore Hospital
06.1982 - 09.1984

Staff Nurse\ Depression Research Unit

Illinois State Psychiatric Institute
06.1981 - 06.1982

Charge Nurse\ Medical-Surgical Unit

Woodlawn Hospital
06.1980 - 06.1981

Associate Degree - Nursing

Olive-Harvey College

Baccalaureate of Science - Health Arts

University of St. Francis

Similar Profiles

CREATE PROFILE
DuVeen V. Blaye