Julie C. Lalli, MSN, RN

Primary Responsibilities:

• Conducts reviews of member and provider appeals; as a TPA-familiar with 100s of health plans
• Analyzes claim adjustment and claim history; wide variety of clinical cases-ED, In-Patient Acute/PAC confinements, Behavioral Health, Genetic Testing, Procedures, DME, Specialty Drugs, etc.
• Reviews denied service in conjunction with policies and procedures, benefit plans, federal and state regulations, and clinical criteria to and renders approval when appropriate
• Extrapolates and summarizes medical information for review by UMR Medical Directors and Independent Review Organizations, as needed
• Balances the need to produce high quality work with meeting timeframes and production goals; meeting and or exceeding company metrics in 2025
• 7 years of InterQual experience; recent ASAM certification
• Manage assigned caseload in an efficiently and effectively manner utilizing time management skills; caseload 18-30, volume per hour metric meets or exceeds in 2025

Primary Responsibilities:

• Clinical Care Coordinator/Review Nurse serves as the link between patients and the appropriate health care personnel, the CC is responsible for ensuring efficient, smooth, and prompt transitions of care. Onsite & Remotely
• Perform Acute, SNF, LTAC, IRF assessments on patients using clinical skills and utilizing CMS criteria upon admission to PAC setting and periodically through the patient stays
• Review targets for Length of Stay (LOS), target outcomes, and discharge plans with providers and families
• Complete all PAC concurrent reviews, updating authorizations on a timely basis-review/authorizations completed within 24 hours of receiving clinical
• Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services
• Engage with patients, families, or caregivers telephonically weekly and as needed
• Assess and monitor patients’ continued appropriateness for PAC setting (as indicated) according to CMS criteria, using
• When naviHealth or Optum is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forward to licensed physicians for review and issuance of the NOMNC when appropriate
• Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits)
• Adhere to all local, state, and federal regulatory policies and procedures

• Led strategic initiatives to drive organizational growth and enhance operational efficiency.
• Personally and effectively responded to insurance denials, 95% overturned
• Established strong partnerships with vendors, suppliers and key stakeholders-SNFS, ALFs, UH/CCH hospitals and and payers to improve collaboration and ensure alignment with business requirements
• Transformed Cleveland branch from a 3-Star to a 4.5-Star home care location. Maintained Mansfield at 4.5-Star
• Deficiency-free CMS (triennial) surveys for both locations in 2018.
• Ensured patient satisfaction and employee engagement were at or above benchmark levels; achieved Home Care Elite Status in 2018

• Prepared Home Care and Hospice/Pal Care divisions for successful CMS triennial survey in 2016; worked closely w CMS surveyor(s)
• Re-designed the clinical operations workflow at the frontline (intake), manager, and field team levels; resulting in 25% increase of daily new case volume, increased productivity of field staff and decreased cost/mileage
• Improved field staff understanding of managed-care and increased payer-mix by increasing non-Medicare volume
• Participated in various CCF task force teams/projects-RNC 2016, Hospital at Home program, SNF at Home program.
• Presented at monthly CCF orientations; provided education to all new employee related to HH/Hospice/Pal Care services

• Re-designed field staff caseloads by geographical strategy planning and continuous monitoring to decrease drive-time; increased visit volume/day
• Key clinical role to interface between Summa at Home services, SummaCare (payer) and Summa's home infusion company for increasing types of specialty infusion services in the home; leading to earlier discharges to home or ALF
• Collaborated with SummaCare's Managed Care Contract team to present home care programs to external customers
• Created a Behavioral Health RN home care team consisting of ANCC certified mental health RNs- for all payer patients.
• Created and implemented a Behavioral Health (BH) Nursing Home and ALF Dementia Program for SummaCare members provided by BH RNs and SLPs (cognition)
• Expanded SAH services into key SummaCare ALFs/SNFs; resulting in improved: communication between ALF/SNF-SummaCare Physicians/NPs and SAH, quality care delivery, and reduction in ER/readmissions;

• Recruited and hired to create and build a Clinical Programs division to support CSI's home infusion and post-acute network management services in Ohio.
• Partner with the VP of Network Management and attended 5-10 hospitals and health plan providers to assess needs and provide program support for post-acute clinical services in the home
• Designed, presented to and was awarded "Care Transitions" home-care programs to several major payers for their Medicare Advantage members, to reduce hospital re-admissions, improve patient satisfaction and improve HEDIS scores.
• Collaborated with MMO clinical team to design. and then deliver. a Readmission Reduction program for MMO for highest risk/utilizers
• Collaborated with Authorization Team manager to create a more efficient auth request form for HH agencies to complete and submit for initial/continued auth requests
• Oversaw compliance for all of CSI with regulatory requirements, ensuring adherence to industry standards and protocols; later hired a compliance director

• Upon hire, initially charged with the transition from a non-skilled (private-duty) home care provider to a skilled home care provider. (Akron)
• Recruited field clinical staff; educated/oriented private duty aides to skilled home health aides; hire additional managers and marketers, as needed.
• Actively participated in the corporate planning and subsequent launching of several national Gentiva clinical home programs- Cardiac Care and Senior Care first in Akron, then to several other locations
• Received "Rookie Operations Director of the Year" for 2007
• Received "Outstanding Branch" award for several years in Akron and other locations. Many locations also received "Home Care Elite" status during 2007-2011.

• Directed operational strategy, enhancing patient care services across home health divisions.
• Managed cross-functional teams to improve service delivery and compliance with healthcare regulations.
• Implemented performance metrics, driving accountability and quality improvements in patient outcomes.
• Collaborated with stakeholders to develop strategic initiatives aligning with organizational goals.
• Started up the 2nd Signature Health HHA in Akron; then assisted owners w start-up of 6 more. Promoted to a corporate role over all the locations (8)

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