J. Elizabeth Caruccio
Summary
Compassionate Registered Nurse with experience offering comprehensive patient care in inpatient and outpatient environments. Telephonic care coordination and remote team management, Works well with diverse complex medical and behavioral health patient populations and fosters trusting relationships to improve outcomes. Efficiently collaborates with healthcare team to advance patient care.
Overview
17
17
years of professional experience
1
1
Certification
Work History
RN Care Manager
Patient First
04.2019 - Current
- Developing and maintaining strong relationships with Patient First physicians and support staff to integrate care management into their practices
- Work with QIC Project Director to define quality measures and develop protocols for patient care using nationally recognized evidence-based care
- Provide team training on industry care management standards
- Provide patient care coordination and education on maintaining optimal wellness.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Audited charts and reviewed clinical documents to verify accuracy.
- Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Participated in nursing simulation activities, evidence-based practice project implementation and competency development to further nursing education.
- Organized and managed care of patients undergoing various therapies and procedures.
- Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols.
Manager, IP Integrated Care Management
Sentara Martha Jefferson Hospital
03.2017 - 07.2018
- Responsible for managing and coordinating the patient care transitions program
- Work in close collaboration with the multidisciplinary team in order to achieve optimal clinical and financial outcomes
- Serve as a mentor by modeling professional practice consistent with organizational goals
- Responsible for assisting in the development of the departmental budget, compliance with federal, state and regulatory requirements and representing the department on multiple committees to include utilization management, quality and safety and readmission oversight
- Project management and strategic planning.
- Managed and motivated employees to be productive and engaged in work.
- Accomplished multiple tasks within established timeframes.
- Maintained professional, organized, and safe environment for employees and patrons.
- Resolved staff member conflicts, actively listening to concerns and finding appropriate middle ground.
- Cross-trained existing employees to maximize team agility and performance.
- Maximized performance by monitoring daily activities and mentoring team members.
- Onboarded new employees with training and new hire documentation.
- Monitored and analyzed business performance to identify areas of improvement and make necessary adjustments.
- Communicated clearly with employees, suppliers and stakeholders to keep everyone on same page and working toward established business goals.
Director of Utilization Management
Riverside Health System
01.2016 - 12.2016
- Responsible for Inpatient Utilization Management function for three Riverside Health System Acute Care Facilities
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Devise or identify solutions for irregular requests and issues.
- Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
- Responsible for Denial and Appeal functions for these acute care facilities
- Overall policy and operational accountability for UM Department
- Oversee team members who are responsible for review of all admissions, concurrent and retrospective
- Develop and revise policies and procedures, monitor and direct team
- Ensure up to date with regulatory changes
- Collaborate with payers, providers and other health system departments
- Chair monthly UM Committee meetings and represent UM Department at multiple interdepartmental collaborations
- Chair multiple process improvement interdepartmental projects
- Budgeting and resource allocation for department
- Reimbursement oversight for multiple payers
- Hiring, team member evaluations, disciplinary actions, scheduling
- Interdisciplinary project management.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Served as subject matter resource, providing information related to [Type] situations.
- Performed admission reviews based for medical necessity based upon [Type] specification.
- Supervised and maintained all utilization review documentation through [Software].
Clinical Services Supervisor
Aetna
11.2014 - 12.2015
- Organize, develop and ongoing management of team of RNs, LPNs and SWs, who are providing complex case management and care coordination to high risk Medicare/Medicaid population in both Richmond and Hampton Roads, VA markets
- Provide staff training, education and mentorship
- Currently, have 14 direct reports
- Completed hiring, onboarding and ongoing evaluations and support
- Direct marketing and strategic planning
- Reporting to client and senior management
- Daily use of Outlook, Microsoft Word, PP, Excel as well as other software applications.
- Assisted with training and development of team members.
- Handled customer complaints and inquiries.
- Monitored team's performance and gave feedback when necessary.
- Updated job knowledge by attending workshops, training sessions and educational opportunities.
- Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
- Participated in team meetings and training sessions to stay informed about product updates and changes.
- Responded to customer requests for products, services, and company information.
- Handled customer inquiries and suggestions courteously and professionally.
- Clarified customer issues and determined root cause of problems to resolve product or service complaints.
- Provided primary customer support to internal and external customers.
Team Lead, Complex Care Management
Virginia Premier Health Plan
02.2013 - 11.2014
- Conduct daily huddles with Level 3, Provide daily guidance and resource information for Level 3 Case Managers
- Case manage complex medical and behavioral health MCO members
- Work collaboratively with all members of the health care team to achieve optimal clinical outcomes for members through improved access to care
- Provide guidance in navigation of health care system and appropriate use of resources
- Staff education on HEDIS measures and preparation for NCQA audits.
- Trained new team members by relaying information on company procedures and safety requirements.
- Coached team members in techniques necessary to complete job tasks.
- Worked different stations to provide optimal coverage and meet production goals.
- Evaluated employee skills and knowledge regularly, training, and mentoring individuals with lagging skills.
- Minimized resource and time losses by addressing employee or production issue directly and implementing timely solutions.
- Managed schedules, accepted time off requests and found coverage for short shifts.
- Directed and supervised team of 14 engaged in team training and development.
Care Manager
Optima Health Plans
03.2008 - 02.2013
- Complex case management for the MCO Medicaid population
- Provide case management training and education for two groups of nursing students, Sentara RNs and EPCI RNs who rotated through case management training every three months
- Share Point Committee - member
- Reorganized entire Share Point site and acted as Committee Chair for Share Point Resource Subcommittee.
- Educated clients and families on community resources, treatment options and health care services to better manage conditions.
- Participated in team meetings and trainings to stay updated on best practices and new developments in care management.
- Responded to emergency situations and provided support to promote client safety and wellbeing.
- Established and maintained relationships with clients, families and community partners to coordinate services to meet client's needs.
- Communicated with healthcare providers to facilitate continuity of care.
- Evaluated clients progress and adjusted service plans to address areas of concern.
RN Care Manager
Patient Advocate Foundation
01.2007 - 02.2008
- Worked with patient/family and their insurer and all members of the health care team in order to help navigate the healthcare system, improve access to benefits and obtain improved clinical and financial outcomes
- Worked with patients throughout the US
- Provided education on Medicare, Medicaid and commercial insurance plans, as well as social security disability, insurance appeals and COBRA.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Audited charts and reviewed clinical documents to verify accuracy.
- Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Organized and managed care of patients undergoing various therapies and procedures.
Education
MBA - Healthcare Concentration
George Washington University
Washington DC12.2015
Bachelor of Science - Nursing
Wagner College
Staten Island, NY12.1988
Skills
- Prioritizing/Managing Deadlines
- Identification of process improvement opportunities and leading teams to achieve results
- Professional staff training and education
- Project Management
- Strategic Planning
- Develop and organize new team, lead both virtual and onsite teams
- Medicare/Medicaid and MCO population management experience
- Strong critical thinking skills, problem solving ability and crisis management
- Outstanding oral and written communication skills; excellent computer skills
- Promotion of Health and Disease Prevention
- Training Junior Team Members
- Medication Side Effect Knowledge
- Staff Supervision
- Telephonic Triage
- Disease Management Programs
- Project Implementation
- Mental Health Care
- Patient and Caregiver Education
- Diabetes and Nutrition Education
- Complex Problem-Solving
- Care Plan Development
- Patient and Family Advocacy
- Patient Education
Accomplishments
- Utilization Review Committee for Sentara Martha Jefferson Hospital-standardizing reporting structure
- ED – UR Department: Riverside Health System - Process Improvement Project Chair for work flow improvement regulatory letter compliance
- Utilization Management Department: successful oversight of DNV Survey evaluation
- Case Management Orientation Manual Development and Training Implementation
Certification
Registered Nurse/Commonwealth of VA CCM, Certified Case Manager CPR, ACLS, PALS Certifications
Affiliations
Accomplished Registered Nurse with over 35 years of professional experience in diverse clinical and nonclinical environments. Experienced in case management, disease management and utilization management with successful progressive leadership. Extensive experience working directly for both health systems and payers.
Timeline
RN Care Manager
Patient First
04.2019 - Current
Manager, IP Integrated Care Management
Sentara Martha Jefferson Hospital
03.2017 - 07.2018
Director of Utilization Management
Riverside Health System
01.2016 - 12.2016
Clinical Services Supervisor
Aetna
11.2014 - 12.2015
Team Lead, Complex Care Management
Virginia Premier Health Plan
02.2013 - 11.2014
Care Manager
Optima Health Plans
03.2008 - 02.2013
RN Care Manager
Patient Advocate Foundation
01.2007 - 02.2008
MBA - Healthcare Concentration
George Washington University
Bachelor of Science - Nursing
Wagner College
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