Kelly Remy

Responsible for managing all accreditation activities for a line of business, region of the company, standards set, and/or enterprise wide which are necessary for attaining and maintaining accreditation from various accrediting organizations, such as URAC and NCQA.

• Interfaces with internal and external clients, quality committees, and departments in the review of quality improvement data and in the implementation of appropriate interventions to effect improvement.
• Manages the overall accreditation processes and resources required to successfully lead the team.
• Evaluates, interprets and summarizes accreditation guidelines and manages the process for accreditation activities.
• Identifies appropriate resources and accountabilities for project teams involved with accreditation.
• Conducts the ongoing evaluation and interpretation of quality standards and accreditation standards to ensure compliance through reporting and measurement studies/ methodologies.
• Serves as expert resource to quality committees and business owners across the organization. Leads and provides oversight of quality studies/projects.
• Facilitates project management and develops comprehensive accreditation work plans by establishing deliverables, accountabilities, and timelines.
• Performs quantitative and qualitative analysis of quality related data and reports activities, improvements, and recommendations to the quality committee.

• Responsible for continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborates with providers to assess members' needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• Serves as a team lead and responds to the most complex medical issues, ensures consistency in benefit application, and may lead cross-functional teams, projects, initiatives, and process improvement activities.
• May serve as departmental liaison to other areas of the business unit or as a representative on enterprise initiatives.

• Responsible for continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborates with providers to assess members' needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• May serve as departmental liaison to other areas of the business unit.

• Aided with induction of labor for women suffering from complications such as preeclampsia.
• Assisted physician during delivery, examination and surgical procedures by anticipating needs, encouraging patient, and attending to baby after birth.
• Coached new mothers with breastfeeding techniques, postpartum self-care and infant care to promote easier transition into motherhood.
• Managed epidural analgesia infusions and monitored vital signs during labor and delivery.
• Facilitated smooth transitions between prenatal care, labor, delivery, postpartum care, ensuring continuity of care for patients.
• Anticipated potential complications early in the labor process through vigilant assessment of both mother and fetus vital signs data.
• Responded to emergency situations such as pre-eclampsia, early labor, and fetal distress.