Kimberly Hubbard
Summary
Hardworking and passionate Registered Nurse Case Manager II with success of 25 years of experience of providing individualized patient/member care. Works well with simple and complex patient/member populations and fosters trusting relationships to improve outcomes. Efficiently coordinates all levels of healthcare professionals, physicians and administrators to advance patient/member care and support. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Ready to help team achieve company goals. Desire RN Case Manager II position to continue my wish to remain happily employed with Elevance Health. Am known as a very good conscientious nurse who is able to engage with members, actively listen to the member and their concerns, and successfully manage their needs with satisfaction.
Overview
17
17
years of professional experience
1
1
Certification
Work History
RN Case Manager II
Elevance Health
09.2019 - Current
- Time at Elevance Health has been spent in 2 regions, Group Retirees Solutions (GRS) and West Region Dual Special Needs Plans (DSNP)
- Telephonically responsible for performing care management activities for members with complex and chronic needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care.
- Effectively evaluates member's health care needs and helps to ensure member has access to services.
- Helps to coordinate care with members of the interdisciplinary team and external providers and vendors in order to meet members identified needs.
- Effectively works to resolve identified issues with authorizations, denials, and access to care.
- From August of 2023 to current on West Region DSNP (Medicare Advantage/Medicaid dual members), have been working under the Model of Care capacity as a high-risk primary panel nurse.
- Under Model of Care (MOC), review member's Health Risk Assessment (HRA), updates it as needed to identify individual needs and gaps and then links the member to any interdisciplinary referrals, services, or community resources the member may need. Individualizes the care plan and creates smart goal for member.
- Under MOC, review the benefits with member to ensure member has a good understanding of their plan dental/vision/hearing/transportation/OTC-Everyday Essentials benefits/SilverSneakers-gym. Ensure all questions are answered about their plan.
- Under MOC, discuss prevention and offer to assist member in discussion with and scheduling appointment with provider to complete needed prevention screenings/vaccines.
- Under MOC, provide community resources for them member and/or refer the member to services such as Personal Emergency Response System, Social Determinants of Health referral (SDoH), In-home Supportive Services referral (IHSS), Medicare Community Resources & Support (MCRS), TX Long Term Services and Supports for initial Personal Assistance Services (PAS), Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), Pharmacy, Social Work/Behavioral Work, Dietician.
- Under MOC and CDP, collaboration with the IPAs (Independent Providers Association) to coordinate care of members.
- Under Complex Discharge Planning (CDP) From August 2022 to April 2023 (under West Region DSNP and GRS, coordinated the transition of members from their facility (inpatient or post acute facility) to their next level of care, such as home.
- Under CDP, the transition plan included assisting with the set-up of durable medical equipment (DME) and home health services.
- Under CDP, welcome home call included red flags to report, review of discharge instructions, medications, if follow up appointment has been made, confirming post discharge services.
- Under CDP, interfaced with Medical Directors and Leadership regularly in planned rounds to discuss member plan of care
- Under GRS, worked under several different program types, Post Discharge Management (PDM), SWAT, Complex Case Management (CCM), and Care Coordination (CC) cases.
- Under GRS, our team consistently met the performance expectations required by the contract for engagement with the members.
- Under GRS, was part of a pilot program through Valued Based Program where CM met weekly with the Case Management director of a participating hospital to discuss members who were inpatient in order to partner together for care transition.
RN Case Manager
Cedars Sinai Medical Center
10.2011 - 04.2019
- Expert knowledge in performing admission reviews based on medical necessity for Medicare and Medi-cal patients utilizing InterQual criteria and utilizing nursing critical thinking and provider discussion for commercial payers via chart review.
- As case manager, arranged repatriation back to home countries and inter-state, lateral acute transfers, and transfer back to in-network facilities through often complex, detailed arrangements.
- Led daily Interdisciplinary rounds to discuss appropriate dispositions and post discharge plans on assigned unit.
- Responded promptly and professionally to patient questions and concerns.
- Acted as preceptor to new students and new employees.
- Verified pre-certification status for surgical patients and worked to obtain additional authorized days via timely telephonic and faxed admission/concurrent reviews with commercial payers.
- Appropriately referred patients not meeting inpatient criteria to Executive Health Resources (EHR) and documenting the determination. Obtained the appropriate and correct admission order, if needed based on the determination.
- Understanding of state and regulatory requirements affecting utilization review/care coordination, specifically CMS, Medi-cal, managed Medi-cal, and HIPAA.
- Managed Observation and proper utilization of the 2-Midnight rule of CMS. Obtained Inpatient/Observation orders appropriately and discussed and documented the plan of care with providers with the Observation order was in place or when the EHR determination is not for Observation.
- Timely communication with required medical providers, claims providers, and payers via phone and fax to provide admission, concurrent, and retrospective review.
- Denial management via verbal and written communication which arranges peer to peer discussions in attempt to overturn denials.
- Functioned as a member in a triad model as the UR nurse, with unit floor care coordinator and the unit social worker, in coordination with the medical providers on a daily basis to review medical criteria for continuation of care or to escalate discharge planning.
- Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
- Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
RN, BSN Fluoroscopy Pain Management Procedures
UC Davis Medical Center
12.2007 - 12.2010
- Provided pre-procedural, intra-procedural, and post-procedural care to patients, including operations of the fluoroscope, IV conscious sedation administration, monitoring of vital signs, and post-procedure education for a variety of fluoroscopy procedures and bedside pain management procedures.
- Maintained sterile conditions upon setup and during procedures.
- Set up sterile trays for procedures and assisted physicians in setup and draping of patients for sterile procedures.
- Start of members IV site.
- Restocking of procedure rooms and IV kits to maintain adequate supplies.
- Act as a resource for the new round of fellow anesthesiologists who rotate through every 6 months.
- Act in a quick manner to administer medication for a patient who may be having a vagal reaction to procedure
RN, BSN Medical-Specialties ICU
UC Davis Medical Center
07.2006 - 12.2007
- Provided comprehensive care to wide range of conditions including head traumas, strokes, cardiac issues, but specifically for the population of radical head and neck resections due to aggressive head and neck cancer often requiring tracheostomy and ventilator placement.
- Provided direct patient care, stabilized patients, and determined next course of action.
- Implemented medication and IV administration, catheter insertion, and airway management.
- Collected blood, tissue, and other laboratory specimens and prepared for lab testing.
- Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and lumbar drains/intracranial pressure (ICP) monitors.
- Monitored patient condition by interpreting and tracking EKG readings, identifying irregular telemetry readings and updating team members on changes in stability or acuity.
- Educated family members and caregivers on patient care instructions.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Monitored patient reactions after administering medications and IV therapies.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Managed patients recovering from medical and surgical procedures including wound care, ostomy care, pressure ulcer prevention, and pain management.
- Recorded details regarding therapies to keep patient charts updated.
- Safe and proper maintenance of multiple IV medication drips via multichannel pole system.
- Worked with multidisciplinary care teams to develop, initiate, and manage patient care plans.
Education
Bachelor of Science - Nursing
Creighton University
Omaha, NE05.2006
Skills
- Elevance Health systems-Healthy Innovations Platform (HIP), Care Compass, Facets, Member 360, Macess, Pluto, CIRS, CSPSUI, Knowledge Library, Healthwise Knowledgebase
- Microsoft Word, Excel, Outlook, Microsoft Teams, Power Point
- EMR systems
- Effectively works remotely with high level of autonomy
- Patience
- Presentation competency
- Analytical thinking
- Problem-solver
- Active listening
- Interpersonal skills
- Compute skills, able to talk and type, use multiple programs at once
- Flexible, organized, teamwork
Certification
IGCM Basic
Timeline
RN Case Manager II
Elevance Health
09.2019 - Current
RN Case Manager
Cedars Sinai Medical Center
10.2011 - 04.2019
RN, BSN Fluoroscopy Pain Management Procedures
UC Davis Medical Center
12.2007 - 12.2010
RN, BSN Medical-Specialties ICU
UC Davis Medical Center
07.2006 - 12.2007
Bachelor of Science - Nursing
Creighton University
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