Katrina R. Layman
Summary
Dynamic health services professional poised for leadership roles, recognized for spearheading impactful healthcare initiatives that enhance patient outcomes. A strong advocate for team collaboration and adaptability, consistently achieving results through strategic planning and regulatory compliance expertise. Known for exceptional communication skills and a proven ability to navigate complex challenges, fostering an environment of trust and innovation. Committed to driving excellence in healthcare management while inspiring teams to exceed expectations.
Overview
22
22
years of professional experience
1
1
Certification
Work History
Director of Care Management
Highmark Wholecare
06.2022 - Current
- Oversight of day-to-day UM Clinical Operations in accordance with business objectives, regulatory requirements, contractual obligations and budget resources.
- Establish performance metrics and evaluation tools to measure the effectiveness of care management initiatives.
- Analyze technology, resource needs and market demand to plan and assess feasibility of company and department goals.
- Provide support to internal departments, delegated vendors and external clients to address member/provider issues and concerns related to UM/Clinical Operations in compliance with medical management requirements for hospitals and physician providers.
- Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting purposes.
- Negotiate contracts with third-party vendors, ensuring timely access to necessary resources while maintaining fiscal responsibility.
- Implement data-driven decision-making processes to inform strategic planning initiatives related to UM services.
- Provide ongoing support to the executive team by offering insights and recommendations on strategic planning initiatives related to UM and member care services.
- Evaluate clinical workflows to identify gaps in service delivery, resulting in actionable recommendations for process improvement initiatives.
- Promoted organizational compliance by staying current on industry regulations and adapting departmental policies as needed to meet National Committee for Quality Assurance (NCQA), Centers for Medicaid and Medicare Services (CMS), and state regulatory requirements for UM functions
- Cultivate strong relationships with key stakeholders across departments for better alignment on shared goals regarding patient outcomes.
- Reduce hospital readmissions through proactive discharge planning and follow-up care coordination efforts.
- Implemented cost-saving measures without compromising quality of care by closely monitoring the use of resources during the review process.
Emergency Room Registered Nurse (Per Diem)
Montgomery General Hospital
08.2022 - Current
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Assisted physicians during invasive procedures such as central line insertions or intubations, ensuring safe and accurate completion of tasks.
- Streamlined emergency room operations by efficiently triaging patients according to the severity of their condition.
Manager, Integrated Care
Highmark Health
01.2018 - 06.2022
- Matrix managed integrated care team of 40 RN's performing UM services for members with complex medical diagnoses; supervised unique team of 15 RN's that included transplant and facility-specific teams; directed and assisted with medical decision-making, appropriate level of care, and safe discharge plans.
- Facilitated and observed daily work volume to assure UM benchmarks and organizational compliance mandates were met (NCQA, CMS, state regulations, etc.).
- Expanded cross-functional organizational capacity by collaborating across departments on priorities, functions, and common goals.
- Established and updated work schedules to account for changing staff levels and expected workloads.
- Maximized productivity by keeping detailed records of daily progress and identifying and rectifying areas for improvement.
- Cross-trained existing employees to maximize team agility and performance.
- Applied performance data to evaluate and improve operations, target current business conditions and forecast needs.
Manager, Care Management
Highmark, Inc.
03.2014 - 01.2018
- Managed team of 12 RN's that performed utilization review services; provided direction and aided with medical decision making, clarification of criteria, policies, etc.
- Facilitated and observed daily work volumes to assure UM benchmarks and compliance metrics were met for NCQA, CMS and other federal and state regulations.
- Project lead for multiple projects centered around care cost initiatives; projects focused on a reduced length of stay for inpatient hospitalizations and reflected positive cost savings.
- Key contact for imaging vendor that overseen daily operations; assisted with resolving authorization, claim, provider/member issues.
- Recruited, retained, and monitored team performance to ascertain operational standards and organizational goals were achieved.
- Delivered feedback to decision-makers regarding employee performance and training needs.
Manager, Clinical Health Services
Coventry Health Care, Inc. An Aetna Company
02.2013 - 03.2014
- Provided management and direction to Medicaid clinical audit and training team; recruited, trained, monitored, and evaluated performance.
- Developed, implemented, and overseen department's activities including policy and procedure, training materials, training requests, etc.
- Collaborated with internal departments to educate employees, providers, and vendors on UM process.
- Performed audits for timeliness, appropriateness, and medical necessity of UM completed by Medicaid health plan teams and prepared reports on audit outcomes.
- Ensured compliance with state, federal, and national accrediting body standards regarding UM decisions and appeals.
Clinical Trainer/Quality Specialist
Coventry Health Care, Inc. An Aetna Company
09.2011 - 02.2013
- Conducted medical necessity review audits to monitor compliance with best practice documentation standards for InterQual criteria; identified areas of opportunities for improvement and additional training/education.
- Performed assessments to outline learning needs accompanied with recommendations and implications such as change in operation, budget, or quality.
- Developed, designed, and implemented policies and procedures and training programs for medical management teams to enhance individual and team value related to job content, technology, and customer service.
- Fostered excellence by example by "setting pace" and being hands-on mentor to clinical staff.
Manager, Quality
Buckeye Community Health Plan
08.2010 - 09.2011
- Ensured compliance with state requirements and accreditation standards throughout organization, including National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS) performance.
- Collaborated with health plan staff at various levels of organization and coordinated QI activities and data reporting to develop program documents, i.e., QI Program Evaluation, QI Work Plan, HEDIS Initiatives, and health plan and accreditation benchmarks.
- Identified targeted areas for improvement that provided more efficient and streamlined workflows across organization, researched and incorporated best practices within organization, and organized activity methods and procedures to achieve business objectives.
- Maximized performance by monitoring daily activities and mentoring team members.
Manager, Provider Services
Molina Medicaid Solutions
08.2008 - 08.2010
- Directed daily operations of provider services call center for Medicaid Management Information Systems (MMIS) for West Virginia Department of Health and Human Resources, Bureau for Medical Services; team received 500+ calls/day.
- Supervised implementation of departmental performance goals, objectives, and policies and procedures for client; monitored and interpreted daily reports against client benchmarks, intervening and readjusting when necessary.
- Evaluated employees' strengths and assigned tasks based upon experience and training.
- Cross-trained existing employees to maximize team agility and performance.
Director, Health Services
Coventry Health Care Of DE
05.2006 - 04.2008
- Created $2M annual budget and developed comprehensive plan to accomplish company objectives while staying within budget.
- Developed and implemented organizational policies and procedures.
- Established performance goals for UM department to reach 100% compliance rates and provided feedback on methods for reaching those milestones.
- Provided documentation of processes to comply with regulations and organizational policies to meet compliance mandates.
- Monitored office workflow and administrative processes to keep operations running smoothly.
- Managed daily operations while overseeing a team of 20 UM and case management RN's across various locations to foster increased productivity.
- Collaborated with quality department to monitor over and underutilization of providers, compliance standards, quality of care, HEDIS reviews, disease management, etc.; worked with customer service and claims to review inpatient and outpatient claims for medical necessity and reimbursement.
- Participated in medical expense review leading to revision of prior authorization rules, clinical criteria, and case management processes; revisions were tracked via medical expense management plan and reflected cost savings.
- Assisted with numerous audits for URAC, CMS, DE and MD Department of Insurance, etc.; all audits successfully passed with UM Best Practices acknowledged.
Director, Health Services
Carelink, A Coventry Health Care Plan
01.2004 - 04.2006
- Managed daily UM operations overseeing team of 12 RN's in multiple locations.
- Established performance goals and provided feedback for UM that increased UM performance metrics to 100% compliance.
- Developed screening tools and criteria for clinical and non-clinical staff; fostered, refined, and implemented UM policies and procedures with oversight of interdepartmental policies involving UM processes.
- Created online authorization tool for providers, decreasing amount of UM inbound calls, allowing provider self-service.
- Monitored annual UM budget to accomplish departmental and organizational goals.
- Worked with benefits administration for authorization logic to result in quicker, more accurate claims adjudication - outcome was positive via plan's provider satisfaction survey and claims adjudication metrics.
- Collaborated with quality department to monitor over and underutilization of providers, compliance, quality of care, HEDIS reviews, and state/federal regulations that impacted and/or potentially impacted managed care.
- Participated in medical expense review leading to revision of prior authorization rules and clinical criteria; revisions were tracked via medical expense management plan and reflected cost savings.
- Assisted with numerous audits for URAC, CMS, WV Department of Insurance, WV DHHR, etc.; audits successfully passed with UM Best Practices noted.
Education
Master of Science - Risk Management and Insurance
Florida State University
Tallahassee, FL05.2020
Bachelor of Science - Nursing
West Virginia Institute of Technology
Montgomery, WV05.1995
Skills
- Strategic Planning
- Coaching and Mentoring
- Process Implementation
- Time Management
- Employee Training Program
- Clinical Staff Management
- Utilization Management
- Performance Monitoring
- Policy and Program Development
- Critical Thinking
- Problem Resolution
- Verbal and Written Communication
Accomplishments
- Exceeded targeted departmental savings by leveraging data analytics to identify UM trends through effectively implementing clinical review strategies based on clinical utilization and claims spend.
- Reduced inventory backlog 100% by developing a cross- training plan that included a contingency design for high producing team members that focused on expediting case reviews and decision making.
- Reduced administrative burden for staff members through automating routine tasks and optimizing workflows and system functionalities that included the use of Artificial Intelligence which led to 25% increased productivity and and further mitigated compliance risks.
- Developed a UM business plan to lessen the risk of noncompliance for the implementation of a new UM platform launch. The plan was centered around inventory, staffing needs, team member skillsets and forecasted volume. The business plan led to a successful platform launch with UM maintaining regulatory compliance throughout the implementation.
- Collaborated with various departmental leaders to develop UM skill and work queue combinations to streamline intake workflows and improve availability to service provider calls, decreasing UM ASA 30% and meeting KPIs 98% of the time.
- Partnered with various team members from multiple departments to launch new products in the marketplace and bring delegated UM work in-house; this included the development of UM platform configuration, UM workflows, regulatory and state contractual requirements, SOPs, training plans, etc., saving the plan $500K annually.
Certification
American Board of Managed Care Nurses Certified Managed Care Nurse 12/2023
Additional Information
- Active RN License – WV – Compact
Timeline
Emergency Room Registered Nurse (Per Diem)
Montgomery General Hospital
08.2022 - Current
Director of Care Management
Highmark Wholecare
06.2022 - Current
Manager, Integrated Care
Highmark Health
01.2018 - 06.2022
Manager, Care Management
Highmark, Inc.
03.2014 - 01.2018
Manager, Clinical Health Services
Coventry Health Care, Inc. An Aetna Company
02.2013 - 03.2014
Clinical Trainer/Quality Specialist
Coventry Health Care, Inc. An Aetna Company
09.2011 - 02.2013
Manager, Quality
Buckeye Community Health Plan
08.2010 - 09.2011
Manager, Provider Services
Molina Medicaid Solutions
08.2008 - 08.2010
Director, Health Services
Coventry Health Care Of DE
05.2006 - 04.2008
Director, Health Services
Carelink, A Coventry Health Care Plan
01.2004 - 04.2006
Master of Science - Risk Management and Insurance
Florida State University
Bachelor of Science - Nursing
West Virginia Institute of Technology
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