Kimbaly Alaniz
West Monroe,LA
Summary
Specialty Referral Case Management Coordinator with 7 years of functional case management leadership experience. Enacts strong and collaborative approach across care continuum and manages workflow to support dynamic teams. Spearheads operational effectiveness and efficiencies to develop quality improvement activities and achieve financial goals.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Specialty Case Management Coordinator
Affinity Health Group
01.2017 - Current
- Supervise the Specialty Referral Case Management team
- Training new team members as well as ongoing evaluation and changing processes as needed
- Work in collaboration with the patient, the patient’s referring and/or primary care provider and a multi-disciplinary team, employing a variety of strategies, approaches and techniques to manage a patient’s physical, environmental and psycho-social health issues in order to assist the patient in receiving the specialized care he/she requires
- Prioritize referral case load for department employees and ensure urgent patient referrals are expedited appropriately
- Answer any questions which patients or referring providers may have as they arise
- Establish a close working relationship with the specialty clinics at various healthcare facilities in order to facilitate communication and urgent scheduling of patients in need of expedited medical/surgical treatment
- Arrange transportation with the patient's insurance plan when the patient does not have transportation to their appointments once scheduled
- Contact the patients’ insurance company when there are mileage limits on their benefits to request an override when the specialty facility location exceeds this with verification that there is no other closer specialist providing services in their network
- Update the patient’s EMR with appointment information, any delays, or other issues encountered and route to referring provider to ensure they are aware of the status of the referral as well
- Communicate with providers when needed or when asked for feedback
- Train all medical providers and nursing staff on the referral/intake process and the outside facilities’ services available
- Communicate with patients or families to assess needs and develop an individualized plan regarding specialty services needed in collaboration with physician and all members of multidisciplinary team based on the outcome of specialty evaluations or referral outcomes
- Monitor patient's progress until they are seen by the outside specialist, intervening as necessary and appropriate to ensure the plan of care and services we provide are patient-centered, appropriate, and effective during the interim period awaiting the patient's specialty appointment
- Maintain established departmental policies and procedures, objectives, safety, environmental, and infection control standards
- Cooperate with other personnel to achieve department objectives and maintain good employee relations, interdepartmental objectives, and organizational policies
- Effectively manage special projects and other tasks as assigned
- Act as a liaison between hospitals, physicians, health plans, patients, and other referral service providers.
Clinical Care Manager
Affinity Health Group
01.2016 - 01.2017
- Created the Clinical Care Management Program for AHG with input from The Quality team to meet PCMH and NCQA requirements
- Created policy and procedure for the CCM program alone
- Created the CCM program guidelines
- Worked with GE to build a care plan within Centricity to meet the PCMH/NCQA requirements of providing care plan in writing
- Created reports with AHG Health IT department to identify patients meeting criteria for the CCM program
- Managed the program alone for a total of 26 clinics to date
- Accountable for the implementation of the CCM goals
- Directly responsible for the development and progression of patient care plans
- Responsible for reporting and review of Care Management enrollees and managing outcomes and effectiveness of the program
- Direct contact with the patients, providers, and clinic staff for assessment, education, coordination, and execution of the care plans
- Directly works with facility discharge planners and Social Worker to coordinate transition for Affinity patients enrolled in the care management program to the home or additional facility when hospitalized
- To identify, provide and coordinate services for patients with complex co-morbidities
- Facilitate processes to actively assist patients and providers with the management of complex conditions
- Coordinate access to needed resources
- To systematically assess the characteristics and needs of our patient population and sub-populations
- Maintain, review and update as needed CCM processes and resources to address patients’ needs
- Identify processes which specifically outline sources of information to identify patients for CCM
- Identify appropriate referral avenues for patients to be referred to CCM and other resources
- Maintain a Care Management system which supports the Clinical Care Management program by providing necessary evidenced-based clinical guidelines, algorithms, assessments, documentation, automatic prompts for CCM follow-up and automatic documentation of staff demographics (i.e., staff patient’s name, date and times of input or activity)
- Ensure CCM activities address the assessment of individualized development of CCM plans which identify the patients’ health status, history, medications, condition-specific issues, activities of daily living, cognitive and mental health status, life-planning activities, and cultural and physical preferences and limitations
- Ensure the identification of barriers to adherence and a plan to overcome them, progress assessment, prioritization of goals, follow-up and communication of self-management plans and support self-care and shared decision making as well as involvement of caregivers and providers and referrals to resources
- To incorporate patient preferences and lifestyle goals in their plan of care
- To provide plan of care in writing to patient/family/caregiver after reviewing and thoroughly explaining the care plan verbally
- To identify treatment goals.
Clinic LPN
Affinity Health Group
01.2011 - 01.2016
- Responsible for assisting physician with patient examination and treatments
- Accompanying physician on hospital rounds and in the operating room for Surgeries and assisting in surgeries when necessary at various facilities
- Ensured that all precertification requirements were met and obtained prior to scheduling or performing any testing or procedures
- Entered physician’s hospital charges with correct CPT codes, and ICD 10 codes for hospital as well as in-office procedures, hospital rounds, consultations, admissions, and discharges into the patient’s electronic medical record and verified that the accompanying documentation was present to ensure accurate and timely filing and billing
- Documenting all patient care, observation, and activities according to professional standards and procedures
- Thoroughly educate and describe various procedures to patients and family members during pre and post-operative period as well and before and during cancer treatments or testing and anytime they’re coping with an illness
- Maintain confidentiality regarding patient and business functions of the organization
- Provide clinical triage/communication as defined by protocol or physician instructions
- Perform basic medical procedures under the supervision of a Physician (e.g
- Lab draws, dressing changes, immunizations, medical injections/administration
- Administer medications according to the standards, polices, procedures, and/or guidelines
- Set up and assist physician with various procedures in the office and sterilizing equipment properly after use
- Observing aseptic technique and all other federal mandates (i.e
- OSHA, etc.) Obtaining specimens using proper technique, and following policy and procedure for labeling
- Verify that all test results are received in a timely manner and reported to the physician upon receipt
- Calling physician with urgent results when appropriate
- Arranging all referrals to specialists as appropriate and ensuring all applicable records are sent prior to the appointment as well as making sure the consultation notes are received promptly and forwarded to the physician once patient has been seen by the specialist after the visit takes place
- Assisting in emergency situations under the direction of the physician
- Update billing, insurance, and coding information as appropriate
- Attending required in-service training (e.g
- CPR, Safety, and Infection Control)
- Assist with identifying methods of improving patient care and improve the clinic as a whole
- Maintaining current knowledge and skills in clinical practice including any required continuing education units, promoting professional growth
- Perform other duties and responsibilities as assigned.
Risk Management, Workman’s Compensation Coordinator
FMOLHS
01.2007 - 01.2011
- Directed all aspects of the self-insured Workers’ Compensation Program at Saint Francis Medical Center
- Assessed injured employees to determine level of care required
- Provided nurse case management for injured employees out on total disability to ensure claimants received all the care needed including medical, psychiatric care, or modified job training when required
- Maintained claims related activity in database
- Calculated average weekly wage then calculated TTD payments based on LOWC guidelines and processed disability payments when claimants were taken off work
- Calculated payroll for employees on light duty and processed payments on all workers’ comp medical claims
- Supervised claimants while on modified duty
- Created a modified/light duty program for SFMC to reduce lost time on yearly OSHA logs at all three SFMC facilities
- Worked with managers to find suitable modified duty for claimants
- Worked with Human Resources to ensure claimants completed and returned the required FMLA documentation and worked with physicians to obtain proper documentation for FMLA when employees were placed on medical leave as well as when they were returned to work
- Counseled and disciplined employees who violated policies and procedures
- Reviewed all workers’ comp cases for qualification under Second Injury Fund
- Negotiated settlements and dispositions
- Assisted attorneys in defense and litigation
- Maintained yearly OSHA logs for three different facilities
- Prepared reports for other hospital management
- Performed ergonomic reviews and various other risk analysis
- Served on the Environment of care Committee as a risk analyst to evaluate patient and visitor falls and compiled data and track patterns in order to analyze possible ways to reduce injuries to patients and visitors
- Evaluated every incident report submitted for all three SFMC facilities to determine if root cause analysis would be indicated
- Investigated significant medication, surgical and various other errors reported to my department
- Assisted attorneys with medical malpractice cases when asked to review medical documentation, investigate policies as to how they pertained to each case etc
- Worked directly with Vice President of Human resources to re-write an outdated Workers’ Compensation policy for the hospital which resulted in an increase in incident reporting at all SFMC facilities
- This decreased lost time and productivity for the organization as a whole due to the employee’ access to earlier treatment for a covered injury
- This resulted in a significant reduction in penalties and legal fees due to litigation.
Occumed Clinic Nurse
Saint Francis Medical Center
01.2005 - 01.2007
- Maintained up to date immunization/titer database records for multiple client accounts
- Scanned all work comp records into AS400 system
- Compared lab results with orders to ensure only those tests ordered were performed
- Responsible for compiling all requested medical records
- Performed DOT drug screens, breath alcohol tests, blood work and assessment of injured workers prior to physician evaluation.
Office Nurse, Laboratory and Kid Med Coordinator
Georgianna Burns, MD Independent Pediatric Practice
01.1998 - 01.2005
- Responsible for having knowledge of and ordering all medical equipment/supplies and all medications/immunizations routinely used in the clinic
- Responsible for training two other nursing staff-members
- Responsible for running daily quality controls on complex laboratory equipment
- Maintained and updated patient data and quality control logs
- Administered all IM/SQ medications and vaccinations when required
- Responsible for obtaining consent for all immunizations
- Informed patients of possible side effects prior to administered drugs or vaccines
- Observed patients for signs and symptoms of adverse reactions
- Obtained weight, height, and vital signs in preparation for physician exam
- Documented patient history for routine check-ups and Kid Med screenings
- Coordinated all referrals to specialists
- Obtained all prior authorizations from insurance companies and Medicaid for specialized procedures and medications.
Education
Associates in Applied Science -
Excelsior College
LPN Clinical Training within various healthcare settings in the Shreveport/Bossier area -
Louisiana Technical College, Shreveport-Bossier Campus
Skills
- Client Advocacy
- Policy Knowledge
- Patient Communication
- Teamwork and Collaboration
- Problem-Solving
- Time Management
- Multitasking
- Excellent Communication
- Organizational Skills
- Attention to Detail
- Adaptability and Flexibility
Certification
- Current Louisiana LPN license with 26 years experience
- OSHA Risk Analyst Certification
- Workers’ Compensation Professional Certification
- Legal Nurse Consultant Certification
- DOTD Drug Screen and Breath Alcohol Collection/Testing Certification
References
- Patrick Gary Jones, MD, Affinity Health Group/Vantage Health Plan President/CEO (Retired), 130 Desiard St. Suite 355, Monroe, LA, 71201, (318) 237-4755
- Francis C. Thompson, Louisiana State Representative/Retired College Professor, P.O. Box 68, Delhi, LA, 71232, (318) 282-1234
- Cresha Davis, MD, Ochsner LSU Shreveport-Monroe Stroke Medical Director/LSUHSC Neurology Professor, 4864 Jackson St., Monroe, LA, 71202, (313) 303-2298
- Kamarin Spann, LPN, Affinity Health Group, Supervisor of Clinical Quality Management, 1301 Hudson Lane, Monroe, LA, 71201, (318) 372-2620
- Lynn Kindrix, Saint Francis Medical Center, Director of Community Health Center, 2600 Tower Dr., Monroe, LA, 71201, (318) 355-2363
- Lynn Kindrix, Director, Community Health Center-Saint Francis Medical Center, 2600 Tower Dr., Monroe, LA, 71201, (318) 355-2363
- Lynne LeBlanc, LCSW-BACS, Director of Integrated Care-Blue Cross Blue Shield, 130 Desiard St. Suite 300, Monroe, LA, 71201, (318) 547-9310
- Aristoteles Pena-Miches, MD, Pediatric Neurologist-Saint Francis Medical Center, 500 Hall Street, Monroe, LA, 71201, (318) 789-8702
Timeline
Specialty Case Management Coordinator
Affinity Health Group
01.2017 - Current
Clinical Care Manager
Affinity Health Group
01.2016 - 01.2017
Clinic LPN
Affinity Health Group
01.2011 - 01.2016
Risk Management, Workman’s Compensation Coordinator
FMOLHS
01.2007 - 01.2011
Occumed Clinic Nurse
Saint Francis Medical Center
01.2005 - 01.2007
Office Nurse, Laboratory and Kid Med Coordinator
Georgianna Burns, MD Independent Pediatric Practice
01.1998 - 01.2005
Associates in Applied Science -
Excelsior College
LPN Clinical Training within various healthcare settings in the Shreveport/Bossier area -
Louisiana Technical College, Shreveport-Bossier Campus
- Current Louisiana LPN license with 26 years experience
- OSHA Risk Analyst Certification
- Workers’ Compensation Professional Certification
- Legal Nurse Consultant Certification
- DOTD Drug Screen and Breath Alcohol Collection/Testing Certification
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