Jill Pegouskie
Dundee
Summary
Dynamic Case Manager with a strong background at Heartland, specializing in insurance negotiation and care coordination. Achieved significant revenue enhancements through strategic discharge planning and meticulous clinical documentation. Expertise in collaborating with healthcare teams to facilitate seamless patient transitions, resulting in improved outcomes within managed care environments. Aiming to leverage skills to further optimize patient care processes.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Case Manager
SKLD Case Management Department and Contracting/Credentialing
Plymouth
10.2018 - Current
- Negotiate the appropriate level of care within insurance contract terms for proper clinical reimbursement.
- Communicates information to the care team and facilitates the patient's smooth transition to the next level of care.
- Obtains accurate information from doctors, patients, and payor sources regarding the appropriate discharge plan.
- Attend account meetings as required.
- Maintains a primary focus on census development and revenue enhancement.
- Monitors the census and profitability of managed care patients.
- Leads the weekly IDT meeting for managed care patients.
- Reviews pre-admission clinical information to determine if they meet the criteria for a SAR stay according to InterQual, Medicare, and Medicaid guidelines.
- Processed insurance precertifications for new patients.
- Completes recertification for existing residents.
- Obtain new insurance contracts for all lines of business.
- Completes appropriate applications, rosters, and paperwork for new contracts, and recredentialing.
- Negotiates appropriate reimbursement rates for new and existing contracts.
Case Manager
Heartland Case Management Department
Ann Arbor
03.2013 - 10.2018
- Negotiate the appropriate level of care within insurance contract terms for appropriate clinical reimbursement.
- Communicates information to the care team and coordinates patients' smooth transition to the next level of care.
- Obtains accurate information from doctors, patients, and payor sources regarding the expected discharge plan.
- Develops referrals from hospitals' social service and discharge planning departments, physicians, case managers, insurance companies, and other referral sources.
- Participate in the Marketing Action Plan and Key Account Meetings as needed.
- Acts as a liaison between payors and decision-makers.
- Maintains a primary focus on census development and revenue enhancement.
- Monitors the census and profitability of managed care patients.
- Participate in the weekly census meeting.
- Participate in the monthly managed care meeting.
Account Liaison for Home Health Care, Hospice and Infusion Services
Heartland Home Health Care and Hospice
Ann Arbor
05.2011 - 03.2013
- Educating patients, families, and referral sources about home care, hospice and home infusion
- Coordinates a smooth transition to home for patients and their families
- Assist in qualifying patients for services by gathering information from charts and other clinical documentation for services
- Work closely with office staff to ensure new business goes to start of care
- Visit primary accounts daily
- Implements territory sales plan and coordinates with operational and clinical leadership to ensure extraordinary customer service and fulfill the Heartland Promises
- Establish and maintain relationships with customers and referral sources
- Assist with service recovery issues as needed
Intake Coordinator
Heartland Home Care and Hospice
Ann Arbor
05.2011 - 03.2013
- Company Overview: Heartland Home Care and Hospice is a home care and hospice agency that provides skilled home care and hospice services to patients in their homes.
- Explained home care and hospice service options to potential patients, their families, and referral affiliations.
- Facilitated efficient transfer of patients from inpatient care to residential settings.
- Conducted insurance verifications for new clients.
- Obtaining authorization from insurance companies for services.
- Organized work shifts for nurses, therapists, aides, and social workers.
- Taking report on new admissions to our home care services.
- Assumed responsibilities of Admissions Director in their absence due to vacation or illness.
- Delivered exceptional support to patients, families, and referral sources.
- Assist as needed during the CHAP survey.
- Evaluated patient referrals for diagnoses, treatments, and medications to ensure appropriate care plans.
- Establish and maintain relationships with patients, families and referral sources
- Assist with service recovery issues as needed
- Heartland Home Care and Hospice is a home care and hospice agency that provides skilled home care and hospice services to patients in their homes
Nurse Manager, MDS Coordinator, Restorative Director, Inservice Director
Transitional Health Services of Wayne
Wayne
10.1998 - 07.2007
- Company Overview: Transitional Health Services of Wayne is a 49 bed skilled long term care facility
- Timely completion of the MDS following State and Federal Guidelines
- Initiation and completion of the care planning process
- Oversee the Restorative program which includes supervising the Restorative Nursing Assistant, working with Speech Therapy, Occupational Therapy, and Physical Therapy, routine charting and evaluation of residents for appropriate program interventions
- Ensure that all Certified Nursing Assistants have 12 hours Inservice training yearly following State Guidelines
- Fall Committee
- Behavior Management Committee
- Supervision of other employees including nurses, certified nursing assistants, dietary, and housekeeping
- General Nursing Duties
- Transcribing Physicians Orders
- Administering Medications and treatments to patients
- Patient Charting
- Transitional Health Services of Wayne is a 49 bed skilled long term care facility
- Started in 1998 as a Charge Nurse and was promoted in March 2004 to MDS Coordinator and Inservice Director
- Initiated the Restorative Program currently in place
Education
LPN - Nursing
Toledo School of Practical Nursing
Toledo, OH04-1991
Skills
- Care coordination
- Insurance negotiation
- Clinical documentation
- Patient assessment
- Discharge planning
- Revenue enhancement
Licenses
- MI, 4703077415
- FL, PN5262087
Certification
MI License # 4703077415
FL License # PN5262087
Timeline
Case Manager
SKLD Case Management Department and Contracting/Credentialing
10.2018 - Current
Case Manager
Heartland Case Management Department
03.2013 - 10.2018
Account Liaison for Home Health Care, Hospice and Infusion Services
Heartland Home Health Care and Hospice
05.2011 - 03.2013
Intake Coordinator
Heartland Home Care and Hospice
05.2011 - 03.2013
Nurse Manager, MDS Coordinator, Restorative Director, Inservice Director
Transitional Health Services of Wayne
10.1998 - 07.2007
LPN - Nursing
Toledo School of Practical Nursing