Kylie Dalziel

• Responds to urgent calls from patients and families during weekend hours, assessing situations and providing necessary interventions or coordinating with other healthcare providers.

• Maintains open communication with the primary hospice team, physicians, social workers, and other healthcare professionals to ensure coordinated care

• Provides pain management interventions, manage other symptoms like nausea, dyspnea, and anxiety, and adjust medication regimens as needed

• Performs technical skills, such as Foley catheter administration, oral suctioning and wound cleansing/dressing changes

• Offers emotional support and education to patients and their families regarding end-of-life care, grief counseling, and advance care planning

• Analyzes complex medical claims to identify potential high-cost cases that might trigger the stop-loss coverage, including reviewing medical records, treatment plans, and diagnostic tests

• Utilizes nursing knowledge to understand medical conditions, treatment options, and potential cost implications to accurately assess the risk associated with claimants

• Collaborates with the underwriting team, claims adjusters, brokers, and healthcare providers to discuss complex cases, coordinate care, and manage stop-loss exposures

• Oversees the application of policies and procedures to enhance product profitability and improve risk management

• Monitors trends in large claims, identifying areas for risk mitigation and potential cost-saving strategies

• Develops and implements case management plans for high-cost patients, which may involve coordinating with healthcare providers, negotiating treatment options, and monitoring progress

• Conducts pre-certification, 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 medical necessary, quality healthcare in a cost-effective setting according to contract

• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process

• Assesses, plans and coordinates member's health care needs after identifying gaps in education or resources

• Provides health education, coaching and treatment decision support for members and families

• Applies knowledge of state and federal regulatory bodies; HIPAA, NCQA, Milliman

• Recipient of the Optum Aquamarine Award from the Vice President of Population Health Management for outstanding performance in case management with launch of new client

• Prepares surgical rooms for procedures, monitoring sterile fields and fellow operating room employees

• Administers ophthalmic drops and oral medication pre- and post-operatively

• Educates patients and families about surgery expectations and discharge instructions