Lavonne Daniel

Health Services /claims senior management position manages leaders responsible for the daily inventory and productivity of their teams at the direction of Health Services/Claims Senior Ensures quality and customer focus meets or exceeds standards. Has oversight to ensure the processes, activities and controls are consistently maintained in the areas. Working with the Director to ensure execution of strategic and operations business plans of the respective sites, including global service partners. Establishes strong relationships with clients and stakeholders, ensuring long-term partnerships and repeat business.

-Manages daily operations of assigned teams. Effectively communicates organizational strategies to engage staff and drive desired behaviors.
-Leads supervisors to handle day to die inventory to ensure turn around time guarantees are met.
-Communicates in a style that effectively engages individuals/teams in a virtual environment, with positive support of organizational goals and objectives.
Partners with short and long term capacity planner as well as resource management to deliver operational and client expectations.
-Understand and utilize all Management Operation System(MOS) tools to include Barrier Time Tracker, Daily Schedule Controls, Automated Scorecard, Performance Profile and Daily Production Log.
- Utilizes active management processes to develop direct reports, allowing the team to successfully balance accuracy and quality with productivity to drive positive results.
Assumes responsibility/ownership to remove barriers preventing teams from meeting customer expectation, internal and external.
-Identifies opportunities to implement process and efficiency improvements that generate improved Customer service through quality and productivity initiatives that automate, and streamline workflows eliminating ineffective processes.
-Uses independent judgement and discretion to review and resolve complex issues.
-Partners with Human Resources/Employee Relations on people initiatives including compensation planning, performance management staffing and employee relations concerns/issues.

• Skills: Utilization Management · Microsoft Office · Appeals · Microsoft Excel

Utilization Management Nursing Appeals Supervisor utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration of pre and post-acute provider and customer appeals. determinations. Utilization Management Nursing works within specific guidelines such as, CMS and MCG, and procedures; applies advanced technical knowledge to determine if an appeal will be overturned or upheld. Utilization Management Supervisor is responsible for ensuring high quality, cost-effective, and appropriate allocation of member services, treatments, and resources.

• Effectively manages attendance, schedules, assignments, and compliance expectations to ensure adequate coverage during traditional and nontraditional business hours (weekend, evenings, and holidays as needed) to support the needs of the business.
• Provides oversight, education, support, and coaching to ensure associates' performance meets expectations and metrics.
• Monitors goals for staff; provides ongoing feedback and coaching; conducts annual performance reviews;.
• Maintains an atmosphere of open communication, teamwork, and ownership and empowerment to make informed decisions. Held regular meetings and encouraged open dialogue among all members.
• Support the daily management and operations of the department.
• Oversees utilization management functions which include timely responses to preservice, concurrent service and post service appeals.
• Utilizes reports to monitor appropriate assignment and completion of appeals.
• Monitors documentation of utilization management activities and rationale for all decisions in electronic medical records systems.
• Demonstrated commitment to the organization's core values, leading by example and fostering a culture of excellence.
• Conducted performance evaluations for staff members, identifying areas of improvement and guiding professional development plans.
• Managed diverse team, promoting inclusive work environment that leveraged individual strengths.
• Conducted thorough employee evaluations to identify areas for growth and development, leading to more skilled workforce.
• Educated staff on organizational mission and goals to help employees achieve success.
• Additional duties as assigned- various projects and connections with matrix partners.

• Skills: Microsoft Excel · Microsoft Outlook · Microsoft Word · Microsoft PowerPoint

Provides technical support resource for the NAO staff of clinicians and supervisors to drive accurate, consistent performance and customer service excellence. Partners with the management team and key business partners to influence solution base ideas, key initiatives, and implement continuous improvement and service excellence. Fosters the development of the front line staff's critical thinking skills to support good decisions, results and outcomes. This is done through effective teaching, coaching and support of knowledge, skills and applications of technical workflows, processes and tools. Actively supports the development and mentoring for new coaches. Supports key initiatives or projects focused on service as well as delivers training to specific groups of employees; refreshed and or new technical information. Traveled to Manila, Philippines to facilitate training for initial claim clinical review and provider appeals review.

• Developed comprehensive training materials for new hires, ensuring a strong foundation in quality control principles.
• Spearheaded the adoption of Lean methodologies within the organization, driving significant cost savings without sacrificing product excellence.
• Coordinated cross-functional teams to identify root causes of quality issues and implement corrective actions.
• Monitored key performance indicators to track progress toward quality objectives and adjust strategies as needed.
• Maintained accurate records of all quality-related activities, allowing for rapid retrieval and analysis during audits or investigations.
• Monitored staff organization and suggested improvements to daily functionality.
• Applied coaching techniques and tools to support managers and team members in improving performance.

• Reviews requests for medical necessity redeterminations and claim review for inpatient and outpatient services, utilizing job aids, policy & procedures, Milliman, federal and state mandates and coverage determinations
• Works appeals for Medicare part D and private fee for service
• Acts as a resource to peers
• Served on Mediqueue Question and Answer box for peers
• Precepts new hires and employees learning new processes such as transplant and Medicare appeals
• Serves on behavioral health appeal committee
• Performs peer to peer audits for audit rebuttals
• Works collaboratively with medical directors, market executives, case managers and liaisons
• Works urgent, high profile and complex cases requiring organization, research and outreach
• Able to prioritize and change gears as needed related to business needs
• Participates in meetings to develop new initiative in the department
• Contributes ideas for TMC savings
• Constantly looking for ways for process improvement
• Has received annual bonus in 2006, 2007, 2009, 2010 and 2011 for exceptional work
• Successfully completed the Certified Professional Coder course
• Maintained strict adherence to HIPAA regulations while handling sensitive patient information during the course of case evaluations.
• Played an integral role in the success of organizational initiatives aimed at improving access to care for underserved patient groups by identifying potential disparities during case reviews and offering recommendations for improvements.
• Optimized care coordination efforts by proactively addressing potential barriers to care delivery identified during case reviews.
• Contributed to the development of improved clinical guidelines by participating in interdisciplinary committees and sharing expertise on best practices.
• Ensured compliance with regulatory requirements through meticulous documentation of cases, findings, and recommendations.
• Expedited claims resolution process through comprehensive analysis of medical records and determination of medical necessity for services rendered.
• Reviewed and documented relevant information into data system applications.

• Compiled, handled and audited Designated Record Sets for members requesting their protected health information
• Assisted in decision-making processes where member rights did not clearly meet established criteria
• Provided review of any potentially denied request for access as per HIPAA requirements
• Provided research and resolution to all Statement of Disagreements submitted
• Provided quality audits of member rights request cases
• Assisted in the developing work-flows, job duties and standards for this newly formed unit
• Provided support to the National Appeals Unit processing provider and member appeals related to adverse determinations
• Received Circle of Excellence awards for being flexible and a team player in supporting the National Appeals Unit
• Exceeded production standards set for performance measurement in the both units

• Performed telephonic and onsite review requests for clinical service
• Made coverage determinations for setting and treatment/services requested by participants or attending MD
• Review management referrals for clinical appropriateness while anticipating plans for healthy services
• Evaluated requests for procedures and services, evaluating diagnosis, clinical records and patient history using medical criteria, benefit plans and coverage policies
• Performed short-term case management for non-complex cases providing outreach and collaboration while managing acute episodes with the goal towards return to healthy function
• Evaluated cases using the seven dimensions of health and standard case management tools
• Acted as preceptor and resource for less experience staff
• Received Circle of Excellence for flexibility and commitment to the team

• Performed telephonic and onsite utilization review of inpatient admissions in facilities to decrease costs and maintain high quality of care
• Precertified hospital admission for surgical procedures, home services and rehabilitation facilities
• Assisted patients and families with understanding and making decisions regarding healthcare needs while in the hospital setting and beyond
• Collaborated with attending physicians regarding plan of care for patients to ensure a speedy but efficient hospital stay
• Ran reports such as bed days, end of month and high dollar utilizing multiple software applications
• Performed short-term case management for diagnosis specific members

• Worked independently and as part of a team performing utilization review, monitored and reviewed inpatient admissions and facilitated quality health care
• Reviewed home care, skilled nursing facility and rehabilitation confinements
• Identified and targeted members with special need situations or diagnosis requiring case management intervention
• Utilized criteria based decision support tools to determine medical appropriateness for requested services
• Used computer based record keeping systems

• Provided skilled cost effective nursing assess of primary patients and family needs
• Utilized appropriate resource personnel and agencies in a collaborative effort to provide continuity of care to patients and family
• Worked to discharge patients to home with appropriate services and realistic expectations of third party reimbursement payers
• Participated in writing critical pathways for specific Neurological, Neurosurgical and Ears, Nose and Throat patients
• Participated in developing electronic clinical record
• Worked as charge nurse, coordinating daily activities of a 34-bed unit with the focus on patient assignments, bed assignments, staffing needs and problem solving between staff, patients and patient families