Genevieve Papa

Diligent Clinical Audit Nurse with background in conducting healthcare audits and monitoring compliance with healthcare regulations. Possess strong understanding of quality improvement measures, risk management protocols, and patient safety standards. Known for effective communication skills, ability to work within interdisciplinary teams, and track record of improving overall clinical quality.

Dedicated and adaptable professional with a proactive attitude and the ability to learn quickly. Strong work ethic and effective communication skills. Eager to contribute to a dynamic team and support organizational goals.

Proactive and versatile professional with a dedication to quickly adapting to new challenges. Strong problem-solving abilities and a proven track record of fostering strong relationships with clients and team members. Focused on supporting team success and achieving positive results.

• To enhance my skills and competencies
• To further assist with maintaining standard operating procedures, policy & procedures that meet all program requirements, regulatory requirements while meeting business needs
• Extensive experience in providing Inpatient & Outpatient Medical Management while assessing member specific needs
• I have been recognized for accuracy, attention to detail, and my ability to utilize critical thinking skills while working independently, or in a team environment
• I am focused on meeting deadlines, enterprise goals, and quality service for all members
• Areas of expertise include the following: Research, problem solving, multi-tasking and task prioritization, customer service, ability to effectively communicate and effectively document, Manage Outpatient Services- assess and review clinical information provided to determine the medical necessity according to Medi-Cal Benefit Guidelines, Medicare Guidelines, Commercial HP Guidelines / MCG Guidelines / Apollo Guidelines / NCCN criteria
• Prepare and document into QuickCaps a detailed, organized analysis of the information provided, as well as request clinical information not yet obtained for the Medical Director to review
• Review those cases that do not meet medical criteria with the Medical Director for their determination
• Ensure timely communication with our Provider’s offices when additional clinical information is required, or notifying of the Medical Director’s review determination
• Identify and refer cases appropriately to Case Management and/or CCS
• Create Denial letters and/or Assist auditing denial letters
• Nov/2016-May/2018 Molina Healthcare of California – (UM/CAM) PA Clinical Supervisor, Oct/2013-Nov/2016 Molina Healthcare Incorporated – HCS Clinical Trainer
• Collaboratively worked with MHI CAM/CM to develop and implement standardized training and orientation modules for the Molina Enterprise
• Ensure that all workflow/process training materials developed meet all Regulatory requirements, NCQA certification and Molina’s business needs
• Participated in designing and developing HCS systems training materials as needed for enhancements and transitions to ensure operational success and data entry accuracy
• Responsible for conducting formal trainings to Health Plan Trainers on various HCS clinical applications utilized enterprise wide
• Participated in New Health Plan Start-Up Training for MHSC and MHPR HCS staff
• Conducted training for Case Management Vendor
• Project management on various planning & implementation meetings within the organization
• Scheduled & Facilitated virtual Instructor-Led iLearn classes for InterQual available to all HCS Clinicians across the Molina enterprise
• Assisted with developing evaluation tools and surveys to access ROI on trainings delivered to health plan trainers
• Provide Health Plan support by conducting HCS staff audits to evaluate clinical staff skill level and competency
• Participant in Health Plan ICT Rounds, scribing to provide Health Plan support
• Collaboratively worked with McKesson on designing Education Program for MHPR- Inpatient Medical Director’s Physician-Led InterQual Training
• Currently participating in enterprise resource planning for the upcoming integrated application- mClinical (MedHok)
• July/2013-Oct/2013 Molina Healthcare of Ca
• Long Beach, Ca – CAM (UM) Clinical Trainer
• Responsible for coordinating and facilitating new hire training for HCS staff
• Facilitate trainings for non-clinical, clinical staff, and Medical Directors
• Conduct Quality Improvement audits to assess HCS staff educational needs and service quality
• Evaluate clinical staff skill level and competency and facilitate additional trainings to improve and maintain staff level of clinical excellence
• Ensure that training materials are compliant with clinical training programs in conjunction with program requirements, and Federal & State regulations
• Able to act as an informational and problem-solving resource for various HCS team members
• Aug/2007-July/2013 Molina Healthcare of Ca
• Long Beach, Ca - U.M
• Specialist II / Prior-Authorizations
• Manage Outpatient Services- assess and review clinical information provided to determine the medical necessity according to Medi-Cal Benefit Guidelines / Molina Corporate Guidelines / InterQual / Hayes criteria
• Prepare and document into QNXT a detailed, organized analysis of the information provided, as well as request clinical information not yet obtained for the Medical Director to review
• Review those cases that do not meet medical criteria with the Medical Director for their determination
• Ensure timely communication with our Provider’s offices when additional clinical information is required, or notifying of the Medical Director’s review determination
• Identify and refer cases appropriately to MCM / CCM / PCM, CCS, QI, and Health Education per Molina Policy
• Assisted with auditing denial letters prior to the formation of the denial team
• Assisted with Claims Workflow
• Managed Medicare Outpatient service requests, worked collaboratively with CCM nurses in order to resolve complex member care issues, and met regularly with the Medicare team to update and provide feedback prior to the formation of the Medicare Department
• Assist with training and mentoring of new hired staff
• Feb/2007-Aug/2007 Citizen’s Choice Health Plan Los Angeles, Ca - Case Management Nurse
• Coordination of inpatient care for Medicare members
• Discharge planning and coordination of outpatient follow up care
• Maintenance of daily inpatient census report
• Coordinate out of network transfers and transition to lower levels of care
• Daily contact with Hospitalist, Attending MD’s and Case Managers for plan of care / concurrent review
• Arrange contract agreements2007 Accountable Healthcare IPA Long Beach, Ca - Case Management Nurse
• Coordination of Inpatient care for patient base of 30,000 members
• Discharge planning and coordination of outpatient follow up care
• Maintenance of daily inpatient census report
• Coordinate out of network transfers and transition to lower levels of care
• Daily contact with Hospitalist, Attending MD’s, and Case Managers for plan of care / concurrent review
• Arrange contract agreements
• Referred members to CCS, Health Education and Care Coordination Programs
• Participation in UM Committee meetings 2005 Advanced Medical Management Inc
• Long Beach, Ca - Authorizations Coordinator
• Processed prior authorization requests for patient base of 40,000 members
• Coding using ICD.9, CPT and HCPC codes and entry 80-100 authorization referrals daily
• Maintained excellent relations and communications with clientele

• Excellent ability to train, mentor and supervise/manage workforce
• Experience in training Healthcare Clinicians
• Certificate of Completion: Technical Training with Impact while incorporating the different Adult Learning Styles
• Certificate of Completion: Facilitation for e-Trainers
• InterQual Certified Instructor from 2013-2016
• Experienced in Training Material Design and Development EDUCATION Trident University International BSHS – Public Health/Healthcare Administration Attended from 2016 - 2018, Course Not Completed Career Colleges of America, South Gate, CA Vocational Nursing Program Course Completion 2006 PROFESSIONAL EXPERIENCE March/2021 – Current CalOptima Health – Delegation Oversight, Clinical Auditor Sept/2018 – March/2021 Excel MSO LLC – (UM Dept.) Prior Authorization Case Manager