Elizabeth Deineko

Registered Nurse with 20 years of experience in the areas of inpatient setting, outpatient, 62 bed rehab unit manager, wound care and case management. Hands-on experience managing financial resources and providing exceptional customer service in healthcare facility. Resolves problems quickly. Skilled in managing and maintaining physician orders and supervising nursing staff according to policies and regulations.

RN Case Manager:

• Provides case management through telephonic assessments, care planning, implementation, care coordination, monitoring and evaluation to ensure member receives services and supports required to meet psychosocial, educational and health care needs.
• Develops, facilitates and communicates a plan of care in partnership with the member, caregiver, primary care in partnership with the member, care giver, primary care physician and various others providers involved in the member's care.
• Initiates utilization for preauthorization and post service reviews.
• Interacts with providers and facilities and utilize knowledge of community resources and the member's benefit structure.
• Assist members with coordination of services from various settings as appropriate and recognize quality of care issues escalating them appropriately.
• Participate in case rounds, call coverage, quality improvement initiatives and meetings as required.
• Performs Utilization Review (UR)/Utilization Management (UM) and Case management (CM) duties according to company policy and procedure for international patients living outside of the United States.
• Collects client data and conducts emergent and non-emergent clinical assessment.
• Assists in the referral of patients (international) to most appropriate provider specialty/facility within Network.
• Monitors and screens pre-authorization to most appropriate provider specialty/facility within Network.
• Monitors and screens pre-authorization requests for second medical opinion referrals and /or diagnostic testings.
• Enters and maintains all applicable information related to case in operating software.
• Reviews hospital admissions for medical necessity and assigns length of stay - LOS in accordance with established criteria. Sends out appropriate communication to providers, facilities, member and /or client.
• Refers all cases that do not fall within pre-established criteria to the supervisor for further evaluation and determination of admission approval, procedure or services requested or refer to Medical Director or peer reviewer.
• Performs duties of the discharge planning nurse to contain length of stay.
• LOS and assure that the insured (member/patient) is receiving services withing the 6 Rights: Care, Place, Time, Provider, Price and Outcome.
• Assist with the coordination (within all phases) of a repatriation/evacuation and work in accordance with individual Client Procedures as well as internal Work Instructions and/or Standard Operating Procedures. Report any change insureds (member/patient) condition IMMEDIATELY to make any differing change in plans.
• Evaluates and reviews treatment plan for consistency of care. Develops realistic treatment plan in conjunction with provider recommendations to meet the client's needs while providing the most appropriate and cost effective method of delivering services.
• Performs written and oral communication with other staff to provide case information, recommendations based on medical necessity and policy language and cost indexes to clients.
• Evaluates and determines the availability of resources in conjunction with policy limits and coverage.
• Implements cost management and delivers the most effective treatment plan.
• Maintains current knowledge base regarding medical-surgical cases, utilization management, discharge planning and continued care needs in relation to physician approved criteria/familiar with ICD-10 and how it improves cost containment efforts due to specificity.
• Reports concerns, problems, and quality assurance issues with the correct Department Head for further evaluation and possible intervention. Follows up with corrective action on recommendations made when required.
• Participates in issuing non-conformance and corrective actions as per ISO policy when quality issues or disruptions in services or systems are identified (always think proactively).
• Functions as a clinical resource to non-clinical staff.

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