Summary
Overview
Work History
Education
Skills
Organizations
Timeline
Generic

Kimberly Pearce

Crestwood,KY

Summary

Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Self-motivated professional accustomed to handling sensitive and confidential records while thriving in deadline-driven environments. Adaptable and experienced with advanced technological skills to effectively manage and interpret large amounts of data. Collaborates effectively with multidisciplinary teams to accomplish dynamic initiatives and improves health systems and quality of care.

Overview

17
17
years of professional experience

Work History

Senior Quality Improvement Professional

Humana
01.2022 - Current
    • Successfully managed a Book of Business which included 60 TINs and 3 VBAs.
    • Drove Medicaid quality improvement YOY with an overall increase of more than 5% for book of business
    • Identified trends and assessed opportunities to improve processes and execution.
    • Integrated decision support, clinical pathways and best practices into health information technology to enhance delivery of gap closure information.
    • Collected, summarized and trended provider performance data to identify and strategize opportunities for provider improvement.
    • Partnered with physicians and staff to explore new ways to encourage member clinical participation in wellness and education.
    • Influenced care outcomes by implementing improvements and optimizing health information technology.
    • Established and implemented departmental policies, goals and objectives.
    • Collaborated with cross-functional teams to develop and implement process and system improvements.
    • Monitored PCP offices processes and suggested improvements to daily functionality for overall quality improvement.
    • Provided extensive education to provider off staff regarding HEDIS measures.
    • Aligned projects and daily activities with company vision, strategies and tactics.
    • Built strong working professional relationships with provider office staff to drive quality.
    • Successfully managed core responsibilities with stretch assignments as needed.

SNP Telephonic Care Manager

Humana
01.2019 - Current
  • Team Lead
  • Stretch assignments as needed
  • Maintained 100% quality and 6.5 contacts daily (4.5 required) for 2021
  • Daily Team Schedule
  • Daily Productivity team updates
  • Weekly and monthly Productivity and Quality update
  • WBT and PTO management
  • Weekly educational emails dependent upon trends/needs
  • AOW (Associate of the week)
  • Mentor
  • Focus Group
  • Created Team page and Yammer page for Team Promise
  • Going above and beyond daily to ensure the needs of my team and our members are met
  • Employ a variety of strategies, approaches and techniques to manage a member's physical, environmental and psycho-social health issues
  • Identifies and resolves barriers that hinder effective care
  • Ensures patient is progressing towards desired outcomes by continuously monitoring patient care through assessments and/or evaluations
  • May create member care plans
  • Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas
  • Make decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
  • Follows established guidelines/procedures.

Oncology Telephonic Case Manager

Aetna
01.2015 - 01.2019
  • Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for 50 cases
  • Utilization management: Milliman used in order to approve Oncology treatments prior to infusions
  • Gathered clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment
  • Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
  • Collaborates with the interdisciplinary team to ensure patient quality of care and safety of discharge
  • Promote compliance with federal and state regulations and contractual agreements
  • Develop, implement and maintain compliance, policies and procedures regarding medical utilization management functions
  • Develop, implement, and maintain utilization management programs to facilitate the use of appropriate medical resources and decrease the business unit's financial exposure
  • Compile and review multiple reports on work function activities for statistical and financial tracking purposes to identify utilization trends and make recommendations to management
  • Provides education to physicians, staff and patients/families.

Registered Nurse, Telemetry Oncology Critical Care Unit

Norton Healthcare
01.2013 - 01.2016
  • Daily care of 10 critically ill patients on unit of service
  • Fill in Charge RN for 4 units (Staffing, Codes, unit issues, etc.)
  • Identify patient care requirements by establishing personal rapport with doctors, staff nurses, patients and family members
  • Establish a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families
  • Promote patient's independence by establishing patient care goals; teaching patient, friends, and family to understand condition, medications, and self-care skills; answering questions
  • Assure quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations
  • Resolve patient problems and needs by utilizing multidisciplinary team strategies
  • Maintain safe and clean working environment by complying with procedures, rules, and regulations; calling for assistance from health care support personnel
  • Protect patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations
  • Document patient care services by charting in patient and department records using EPIC
  • Maintain continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs
  • Maintain patient confidence and protects operations by keeping information confidential
  • Maintain nursing supplies inventory by checking stock to determine inventory level; anticipating needed supplies; placing and expediting orders for supplies; verifying receipt of supplies; using equipment and supplies as needed to accomplish job results
  • Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies
  • Maintain a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem-solving methods
  • Norton Cancer Committee Representative.

Family Readiness Program Trainer

NAF Marine Corps Community Services
01.2007 - 01.2010
  • Trained and educated 42 units at 7 Marine Corps bases
  • Supervised 12 NAF employees
  • Large scale Project management
  • Coordinated and delivered all Family Readiness Training
  • Developed new training for growing needs
  • Maintained and updated Family Readiness Resource Guides for units
  • Conducted effective outreach efforts to support units and assess the needs of each individual command
  • Analyzed challenges and program effectiveness
  • Provided World Class Customer Service.

Education

Masters of Nursing Administration -

Aspen University
01.2025

Associate of Science: Nursing -

Galen College of Nursing
12.2013

Skills

  • HEDIS extensive knowledge
  • Proven Leadership skills
  • Project Management experience
  • Utilization management experience
  • High level of autonomy
  • Software skills (EHR, Word, PowerPoint, Excel, Humana platforms to include, MRM, CGX, CRM, Compass, Quickbase, PRM, PMDM, Provider at a Glance, Anvita, etc)
  • Critical Thinking
  • Medical Record Review
  • Procedure Implementation
  • Program Oversight
  • Performance Improvement
  • Quality Improvement Initiatives
  • Healthcare Quality Metrics
  • Clinical Data Analysis
  • Quality Improvement

Organizations

  • American Nursing Association
  • Kentucky Nursing Association

Timeline

Senior Quality Improvement Professional

Humana
01.2022 - Current

SNP Telephonic Care Manager

Humana
01.2019 - Current

Oncology Telephonic Case Manager

Aetna
01.2015 - 01.2019

Registered Nurse, Telemetry Oncology Critical Care Unit

Norton Healthcare
01.2013 - 01.2016

Family Readiness Program Trainer

NAF Marine Corps Community Services
01.2007 - 01.2010

Masters of Nursing Administration -

Aspen University

Associate of Science: Nursing -

Galen College of Nursing

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Kimberly Pearce