Karie Jones
Monrovia,IN
Summary
Health Service Director with over 21 years of experience supporting staff as a subject matter expert in clinical utilization management (UM) and operations. Successfully developed, refined, and standardized processes across the enterprise for efficient and effective operations. Eager to utilize extensive knowledge gained from UM to contribute as a front-line staff member/leader. Particularly passionate about analyzing data and managing projects, excited to apply these skills in leading and supporting enterprise projects and programs.
Overview
22
22
years of professional experience
Work History
Medical Management Operation ManageR/Health Service Director
Elevance
03.2018 - Current
- Workstream lead on ICD/ICA UM Transformation project
- Subject matter expert, (SME), for new Health plan implementations
- Project manager for new health plan implementations and ACMP system migrations
- Test lead for multiple migrations of health plans and implementations of health plans for ACMP
- Drive standardization across all lines of business on UM process and system usage
- Oversight of Medicaid Health Plan's UM operations monitoring and advising on TAT, Auth Chex, pie audits, process improvement, and standardization
- Develop and Maintain process and oversight of Enterprise UM Desktop Processes (DTP's) for Annual SME reviews to ensure up to date.
NURSE MEDICAL MANAGEMENT TEAM LEAD
Florida Health plan
04.2016 - 03.2018
- Daily management and mentoring of the Utilization Management nursing staff.
- Responsible for coordinating the onboarding and on the job training of all new hires.
- Ensure sufficient daily staffing to accommodate daily business needs.
- Implement new processes and procedures to improve the inpatient review process and ensure the members are receiving high quality, cost effective care.
- Write and review processes for health plan Utilization management that incorporate desktop processes, (DTP), quick reference guides, (QRG), and state contractual obligations.
- Audit staff to confirm meeting and exceeding corporate expectations on PIE audits, NCQA, and state TAT standards, and Auth Chex.
- Analyze corporate measures such as PIE audits, TAT, TAT not met reports, Auth Chex, and monitor the IP/OP Pended Auth Reports to identify trends, staff deficiencies and strengths. Utilize these measures as educational training opportunities to ensure meeting corporate metrics. Currently the Florida Health Plan is exceeding expected corporate standards.
- Liaison between the Utilization Management nurses, management staff, and Medical Directors.
NURSE MEDICAL MANAGEMENT UTILIZATION MANAGMENT
Florida Health plan
04.2005 - 04.2016
- Ensured high quality, cost effective care thru Inpatient and Post- Acute utilization management and proactive discharge planning of Amerigroup members.
- Utilization management onsite, telephonically, by fax, and via EMR.
- Applied McKesson Interqual and MCG criteria to determine medical necessity.
- Successfully trained and mentored new hires.
- Subject Matter Expert (SME) for Inpatient Utilization Management for the health plan.
- Proactively implemented new processes, computer systems, and criteria.
TEAM LEAD
Florida National Call Center
04.2004 - 04.2005
- Responsible for secondary reviews on precertification requests.
- Coordinated precertification requests that required Medical Director review with the health plan.
- Conducted new hire training classes.
- Performed on the job training for staff.
- Subject Matter Expert and mentor to staff.
Precertification Nurse and Supervisor
Virginia Beach National Call Center
01.2003 - 04.2004
- Virginia Beach call center nurse and promoted to supervisor.
- Responsible for precertification of inpatient and outpatient authorizations, triage of members for the Nurse Helpline, and managing the day to day operations of call center associates.
Education
Bachelor of Nursing - Nursing
University of Indianapolis
Indianapolis, IN12.1996
Skills
- System Requirements Gathering/testing
- Implementation of new PM processes
- Microsoft Office tools
- Knowledgeable in Elevance UM Operations Policies and Procedures
- Training skills
- Interpersonal communication
- Multitask
- Proficient in FACETS
- Proficient in ACMP/AUMI
- Proficient in AVP
- Proficient in Smartsheet
- CURES Whitebelt Certified
Timeline
Medical Management Operation ManageR/Health Service Director
Elevance
03.2018 - Current
NURSE MEDICAL MANAGEMENT TEAM LEAD
Florida Health plan
04.2016 - 03.2018
NURSE MEDICAL MANAGEMENT UTILIZATION MANAGMENT
Florida Health plan
04.2005 - 04.2016
TEAM LEAD
Florida National Call Center
04.2004 - 04.2005
Precertification Nurse and Supervisor
Virginia Beach National Call Center
01.2003 - 04.2004
Bachelor of Nursing - Nursing
University of Indianapolis
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