Jackie Eshbaugh
Westminster,USA
Summary
Dynamic RN Director of Case Management and Utilization Management with a proven track record in directing care management operations and enhancing team performance. Expertise in implementing strategic initiatives that improve patient outcomes, streamline processes, and ensure compliance with regulatory standards while fostering a collaborative environment.
Overview
20
20
years of professional experience
Work History
RN Director of Care Management & Utilization Management Dept
Advent Health- Porter Hospital
Denver, CO
01.2023 - 01.2025
- Directed the daily operations of the CM and UM Dept, including all aspects of care coordination, care transition and compliance guidelines
- Implemented the Corp CM/UM strategies in order to improve operations & outcomes
- Implemented the Care Management & UM policies, procedures and standards
- Directed Collaboration with UM Physician : review medical criteria, denials & appeals
- Worked collaboratively with UM Team to efficiently address CM & UM concerns/barriers
- Responsible for quarterly Utilization Management Committee w/ PP presentation
- Active committee chair for the CO Medicaid HTP initiations and facilitation/report out
- Active lead of CM/UM team during the AH acquisition & transition to EPIC platform
- Maintenance of CMS guidelines / standards during MAGNET & JACHO accreditation
- Educated and mentored CM/UM staff on data interpretation, EPIC updates, audit results
- Coached/mentored staff to improve performance based on monthly data analytics
- Identified leadership talent & actively developed leadership skills in staff
- Supported diversity objectives of the organization in recruiting and promoting
- Assisted the AH CM /UM Executive Leaders with operating budget for CM/ UM teams
- Implementation of CMS Conditions of Participation for Discharge Planning
RN Director of Case Management & Utilization Review Dept
Post Acute Medical Specialty Hospital
Denver, CO
01.2021 - 01.2023
- Knowledge and successful implementation of the Utilization Review Process, provider denial process with first level Appeals & Grievances
- Implements and maintains departmental goals, plan and standards consistent with the objectives of the organization, NCQA, URAC and JCAHO.
- Led planning, implementation, and coordination of clinical audits and patient satisfaction surveys to ensure high-quality, cost-effective care.
- Developed departmental goals, standards, and objectives aligned with organizational objectives.
- Primary chair and facilitator of Utilization Review Committee and Reporting
- Chair member of the Quarterly Quality and Risk Management Committee, participating in internal and external quality review activities.
- Led and facilitated weekly interdisciplinary team rounds focused on quality care
- Hired, trained, and managed team members, overseeing performance evaluations, satisfaction, and conflict resolution.
- Team building and education in order to improve CM/UR employee satisfaction and excel in quality UR/discharge planning.
RN Supervisor: Care Manager / Preceptor
Anthem Inc
Denver, CO
02.2016 - 12.2020
- Managed telephonic care within RN licensure across 36 states, providing members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans to optimize member health care.
- Conduct assessments and clinical audits to identify individual needs, developing specific care management plans aligned with identified objectives and goals.
- Orient and counsel newly employed case management RNs on care management duties to facilitate support for members with complex and chronic care needs.
- Facilitate member access to appropriate health care resources and financial services based on individual health care needs.
- Assisted with implementation of utilization/care management policies and procedures, scheduled meetings, as well as presented cases for Grand Rounds/Care Conferences.
- Presented multiple powerpoint medical educational seminars to a large team of clinical associates.
Utilization Review Coordinator / Case Management RN
SCL - St Joseph Hospital
Denver, CO
04.2009 - 02.2016
- Conducted clinic case management/utilization review ensuring compliance with state and federal regulations.
- Executed initial, concurrent, and discharge clinical reviews, assessing patient diagnoses to determine appropriate levels of care.
- Assessed medical appropriateness of inpatient and outpatient services through evaluation of assigned ICD-9/DRG codes and application of interqual or Milliman Care Guidelines.
- Participates in the discharge planning process, ensuring adequate and appropriate disposition and post-discharge planning.
- Maintained all required clinical documentation securely within the Allscripts and EPIC information systems.
RN Quality Resource / Senior Care Coordinator
Kaiser-Permanente Foundation
Aurora, CO
09.2004 - 04.2009
- Full-time employment as a Quality Resource and Senior Care Coordinator, initiating the assessment, utilization review, risk management and cost containment implementation measures for the Kaiser- Permanente client base.
- Conducted audits and implemented interventions for senior clients with multiple comorbidities to reduce frequent inpatient readmissions.
- Facilitated assessment and safe repatriation of KP patients to designated core health care facilities.
- Implemented Interqual Care Guidelines to facilitate the level of care.
- Primary role was to assist in maintaining quality of care within the acute care setting.
Education
Master of Science - Health Service Administration
Central Michigan University
Mt. Pleasant, MI01-1997
Bachelor of Science - Bachelor of Science in Nursing
Wayne State University
Detroit, MI01-1991
Skills
- Case Management
- Utilization Management
- Quality improvement
- Performance enhancement
- Compliance management
- EHR Systems
- Process enhancement
- Critical Thinking
- Problem Solving
- Negotiation
- Conflict Management
- Collaboration
- Verbal Communication
- Written Communication
- Microsoft Office Suite
- Interpersonal Skills
Personal Information
Title: RN, BSN, MSHA
Certifications And Memberships
- Member of the American Nurses Association
- Member of the International Council of Nurses
- Compact RN License for Colorado
Knowledge And Skills
- Extensive experience as Case Management/ Utilization Management Director in independently leading, precepting and mentoring a team of Case Managers / Utilization Review clinical staff.
- Excellent knowledge of business trends and issues in Case Management delivery models with skills to integrate best practice & standards into operations.
- Recertification experience with Magnet, Joint Commission Surveys & Accreditation and NCQA.
- Strong knowledge of performance improvement methods with the ability to effectively apply continuous quality improvement concepts to monitor the effectiveness of the Case Management services.
- Responsible for facilitating and adapting to the daily Case Management operations changes, critical thinking and problem solving with minimal supervision.
- Strong negotiation, conflict management with effective problem resolutions.
- Strong verbal and written communication skills.
- Implements and facilitates case management and utilization management programs/audit tools to ensure State and Federal regulatory standards are met.
- Knowledge and implementation of denials, appeals and grievances, under guidelines of CMS & NCQA.
- Responsible for data tracking, identifying trends, process improvement opportunities through chart review/audits and surveys.
- Strong knowledge and application of Microsoft Office products (Word, Excel, PowerPoint, Outlook, Teams & Shared folders).
- Strong organizational and interpersonal skills, with the ability to multitask, and manage a clinical team independently.
- Many years of experience with HEDIS focused EHR, including EPIC, Allscripts & Careport.
- Collaborate with the C-Suite and other organizational leaders to maintain a collaborative professional relationship in order to achieve goals.
Timeline
RN Director of Care Management & Utilization Management Dept
Advent Health- Porter Hospital
01.2023 - 01.2025
RN Director of Case Management & Utilization Review Dept
Post Acute Medical Specialty Hospital
01.2021 - 01.2023
RN Supervisor: Care Manager / Preceptor
Anthem Inc
02.2016 - 12.2020
Utilization Review Coordinator / Case Management RN
SCL - St Joseph Hospital
04.2009 - 02.2016
RN Quality Resource / Senior Care Coordinator
Kaiser-Permanente Foundation
09.2004 - 04.2009
Master of Science - Health Service Administration
Central Michigan University
Bachelor of Science - Bachelor of Science in Nursing
Wayne State University