Judy Payne

Direct supervision of up to 20 Clinical Reviewers including counseling, performance review, time card and PTO coordination, auditing, and metric tracking for ISA and IO Radiation Therapy departments and IO Medical Oncology

• Assists with health plan and regulatory agency audits, meeting department goals, and implementations
• Maintains proper human resource and payroll documents
• Participates in leadership meetings for this department as well as other departments including Work Force Management, Auditing, ISA and IO Supervisor Monthly meetings, and with Physicians.

• Review provider requests for outpatient services including chemotherapy, specialty drugs, and radiation therapy
• Apply established clinical protocols maintaining URAC and NCQA guidelines and principles
• Resource for members and providers
• Maintaining confidentiality and compliance of HIPAA and state regulations
• Training and mentoring new team members to the Radiation Therapy and Medical Oncology programs
• Mentored CRs at all levels to help them achieve their goals
• Collaborated with Manager in developing tools for review.

• Review medical records for accuracy of payment through verification of coding and billing, supporting clinical information, and appropriate guidelines while working independently from home
• Apply medical necessity guidelines based on appropriate criteria
• Maintained standards set for medical records review
• Reviewed Medicare Claims to ensure the site of service was at the appropriate level and place
• Ensured maintenance of confidentiality of PHI and sensitive information while working from home
• Worked until Medicare contract expired.

• Review provider requests for outpatient and inpatient services
• Apply InterQual criteria
• Educated providers regarding review criteria and policy
• Collaborate with internal Case Manager, Medical Directors including Pharmacy Director, and Management
• Specialized reviews of therapeutic requests, including but not limited to Chemotherapy, Radiation Therapy, Specialty Drugs, Physical, Occupational, and Speech Therapies, and DME
• Apply review processes consistent with state Medicaid guidelines and NCQA standards
• Identify quality of care issues and consulted with Quality Management as needed
• Ensure compliance with HIPAA regulations
• Mentored new hires to the Medical Management Department and engaged in continuation intradepartmental education.

• Management of 174 bed Long Term Care Facility
• Scheduling to optimize staffing for unit coverage
• Marketing and Liaison for resident and family relations
• Staff education, development and annual evaluations
• Communication of all weekend shifts, events and activities to DON and Administrator
• Collaboration with internal and external physicians, pharmacists, hospitals, therapeutic services and social services.

• Case Manager for assigned home health patients
• Application of care coordination skills and planning, including but not limited to medication management, wound care, intravenous therapy, and emotional support
• Validation of patient benefits for the purpose of equipment and service implementation
• Education for families, patients, and care providers.

• Charge nurse as assigned
• Emergency and intensive cardiac triage, assessment and care
• Patient and family education.

• Charge nurse as assigned
• Application of nursing process
• Assessment of outcomes and development of treatment interventions specific to disease process and complications of treatment
• Patient and family education.

• Provided patient care in a 10-bed critical care unit for patients undergoing Stem Cell and Bone Marrow Transplants
• Assessment of patient from work up and cell or marrow collection to transplant day
• Also cared for family donors needs after collection was completed
• Charge nurse as assigned
• Assessment of outcomes and development of treatment interventions specific to disease process and complication of treatments
• Patient and family education.

• Patient care through nursing process for oncological surgery and stem cell transplant patients
• Charge nurse as assigned
• Assessment of outcomes and development of treatment interventions specific to disease process and complications of treatment
• Patient and family education.

• Provided care to patients undergoing Bone Marrow Transplants (Unit closed within 3 months and stayed until all patients were discharged)
• Assessment of outcomes and development of treatment interventions specific to disease process and complications of treatment.

• Provided utilization and care coordination services for admissions, discharges, and discharge planning.

• Provided patient care in an oncology unit
• Assessment of outcomes and development of treatment interventions specific to disease process and complications of treatment.

• Provided patient care in an oncology unit
• Implemented nursing process
• Charge nurse as assigned
• Mentored new hires
• Assessment of outcomes and development of treatment interventions specific to disease process and complications of treatment.