Strong leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency. Uses independent decision-making skills and sound judgment to positively impact company success.
Hi, I’m
Jamie Wegforth
Milford,Pennsylvania
Summary
Overview
16
years of professional experience
Work History
Oscar Health Plan
Manager Utilization Management
01.2023 - Current
Job overview
- Developed and maintained positive relationships with payers and regulatory agencies, resulting in increased collaboration and improved outcomes for members and the organization
- Implemented ongoing data analysis and reporting initiatives, resulting in improved decision-making and enhanced quality of care for patients.
- Optimized inventory management systems to maintain adequate stock levels while reducing waste.
Elevance Health
Manager Grievance and Appeals
01.2022 - 01.2023
Job overview
- Successfully managed a team of grievance fourteen associates for an organization with over 1,000 employees.
- Successfully represented the organization in state and federal audits related to grievance management, achieving positive results and minimizing financial risk for the organization
- Facilitated successful cross-functional collaborations for the completion of key projects, fostering strong working relationships among team members.
Brown & Toland
Manager Inpatient Care Management
01.2021 - 01.2022
Job overview
- Managed and motivated fifteen nurse employees to be productive and engaged in work.
- Developed and maintained positive relationships with payers and regulatory agencies, resulting in increased collaboration and improved outcomes for patients and the organization
- Implemented ongoing data analysis and reporting initiatives, resulting in improved decision-making and enhanced quality of care for patients.
Anthem Blue Cross
Manager Grievance and Appeals
01.2019 - 01.2021
Job overview
- Successfully managed a team of fourteen clinical grievance nurses to achieve a 99% resolution rate for member grievances, exceeding the industry standard of 80% for California, Texas, Washington, Colorado Nebraska, and Nevada Medicaid markets
- Conducted root cause analyses for high-risk and high-volume grievances, resulting in the identification of systemic issues and the implementation of process improvements to prevent future grievances
- Successfully represented the organization in state and federal audits related to grievance management, achieving positive results and minimizing financial risk for the organization
Anthem Blue Cross
Senior Concurrent Review Nurse
01.2017 - 01.2019
Job overview
- Conducted comprehensive reviews of inpatient medical records, resulting in timely and accurate determination of medical necessity and level of care, with a 98% accuracy rate
- Maintained effective communication with physicians, care teams, and insurance providers to ensure appropriate utilization of resources and timely discharge planning
- Successfully led a weekend team of concurrent review nurses to achieve 4-million-dollar cost savings to the department through effective utilization management and efficient discharge planning.
Inland Empire Health Plan
Utilization Management Supervisor
01.2015 - 01.2017
Job overview
- Successfully managed a team of eighteen nurses and 15 coordinators in a health plan organization of over 1,500 employees
- Conducted ongoing education and training initiatives for the outpatient utilization review team, resulting in improved clinical competency and enhanced patient care practices
- Maintained compliance with regulatory and accreditation requirements related to outpatient utilization management.
Magnolia Healthcare Management
Utilization Management/Case Manager Supervisor
01.2012 - 01.2014
Job overview
- Managed a team of five nurses and four coordinators in a healthcare organization with over fifty employees
- Analyzed care management data to identify trends and opportunities for improvement, and developed strategies to address identified issues
- Managed relationships with health plan representatives and other stakeholders to ensure that care management services were aligned with contract requirements and expectations
- Provided clinical oversight and guidance to care managers to ensure that patient care was safe, effective, and patient-centered
Visiting Nurse Association Of The Inland Counties, Inc
Field Case Manager
01.2011 - 01.2012
Job overview
- Monitored patient progress closely, adjusting case management plans as needed to achieve desired outcomes.
- Maintained accurate and timely documentation of patient care, ensuring compliance with regulatory and accreditation requirements
- Enhanced patient outcomes by developing comprehensive case management plans tailored to individual needs.
Gentiva Health Services, Inc.
Field Case Manager
01.2010 - 01.2011
Job overview
- Coordinated and supervised home health care services provided by interdisciplinary teams to ensure the highest quality of care, resulting in improved patient outcomes and decreased hospital readmissions
- Maintained accurate and timely documentation of patient care, ensuring compliance with regulatory and accreditation requirements
- Conducted ongoing monitoring and evaluation of patient care plans to ensure appropriate utilization of home health services and resources, resulting in a 5% reduction in unnecessary utilization.
Craven Regional Medical Center
Medical-Surgical Floor Nurse
01.2008 - 01.2009
Job overview
- Administered medications, including oral, intravenous, intramuscular, and subcutaneous routes, and documented medication administration accurately in the patient's electronic medical record
- Educated patients on disease management, self-care techniques, and wellness strategies to improve long-term health outcomes.
- Assessed patients to determine individual needs and develop care plans in coordination with multidisciplinary healthcare professionals.
Education
Craven Community College
Associate Degree from Nursing
University Overview
University of Phoenix College
Baccalaureate Degree
University Overview
Western Governors University
Master’s Degree from Management and Leadership
University Overview
Skills
- Budget Control
- Expense Tracking
- Team Leadership
- Cross-Functional Teamwork
- Performance Tracking and Evaluation
- Operations Management
- Key Performance Indicators
- Documentation And Reporting
- Project Management
- Quality Management
Professional Licenses
Professional Licenses
- Arizona
- California
- Pennsylvania
- New York
Timeline
Manager Utilization Management
Oscar Health Plan
01.2023 - Current
Manager Grievance and Appeals
Elevance Health
01.2022 - 01.2023
Manager Inpatient Care Management
Brown & Toland
01.2021 - 01.2022
Manager Grievance and Appeals
Anthem Blue Cross
01.2019 - 01.2021
Senior Concurrent Review Nurse
Anthem Blue Cross
01.2017 - 01.2019
Utilization Management Supervisor
Inland Empire Health Plan
01.2015 - 01.2017
Utilization Management/Case Manager Supervisor
Magnolia Healthcare Management
01.2012 - 01.2014
Field Case Manager
Visiting Nurse Association Of The Inland Counties, Inc
01.2011 - 01.2012
Field Case Manager
Gentiva Health Services, Inc.
01.2010 - 01.2011
Medical-Surgical Floor Nurse
Craven Regional Medical Center
01.2008 - 01.2009
Craven Community College
Associate Degree from Nursing
University of Phoenix College
Baccalaureate Degree
Western Governors University
Master’s Degree from Management and Leadership
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