LISA BALLERINI
Oxford,MI
Summary
Compassionate Registered Nurse with experience offering comprehensive patient care in outpatient environments. Works well with diverse patient populations and fosters trusting relationships to improve outcomes. Efficiently coordinate with healthcare professionals to advance patient care.
Overview
12
12
years of professional experience
1
1
Certification
Work History
RN, Utilization Management Nurse Coordinator
Aetna Better Health of Michigan
04.2024 - Current
- Under minimal supervision, utilize clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
- Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
- Communicate with providers and other parties to facilitate care/treatment
- Identify members for referral opportunities to integrate with other products, services and/or programs
- Identify 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
RN, Care Manager
Aetna Better Health of Michigan
03.2022 - 04.2024
- Under minimal supervision, developed a proactive plan of care to address identified issues to enhance the short and long-term outcomes, as well as opportunities to enhance a member’s overall wellness
- Use clinical tools and information/data review to conduct an evaluation of member’s needs and benefits
- Apply clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning
- Conduct assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality
- Use a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members
- Collaborate with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences
- Utilize case management processes in compliance with regulatory and company policies and procedures
- Utilize motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation
RN, Care Manager
Blue Cross Blue Shield of Michigan
09.2021 - 01.2022
- Under minimal supervision, lead the coordination lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally
- The multidisciplinary team is inclusive of Medical and Behavioral Health Social Workers, Registered Dietitians, Pharmacists, Clinical Support Staff and Medical Directors
- Use the case management process to assess, develop, implement, monitor and evaluate care plans designed to optimize the members health across the care continuum
- Assess the member's health, psychosocial needs, cultural preferences and support systems
- Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care and promote improved overall health outcomes
- Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services)
- Coordinate care delivery and support among member support systems, including providers, community-based agencies and family
- Advocate for members and promote self-advocacy
- Deliver education to include health literacy, self-management skills, medication plans and nutrition
- Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary
- Accurately document interactions that support management of the member
- Prepare the member and/or caregiver for discharge from a facility to home or for transfer to another healthcare facility to support continuity of care
- Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care
- Secure durable medical equipment and transportation services and communicate this to the member and/or caregiver and to key individuals at the receiving facility or home care agency
- Adhere to professional standards as outlined by protocols, rules and guidelines meeting quality and production goals
- Continue professional development by completing relevant continuing education and Certified Case Manager (CCM)
RN, Clinical Supervisor
Maxim Healthcare Services
Flint, MI
02.2016 - 09.2021
- Under minimal direction, responsible for all clinical activities of the field staff, including preparation and coordination of all clinical reports and progress notes
- Perform medical record audits and provide education where non-compliance is recognized
- Interviewing and hiring of clinical staff, facilitate all new hire orientation
- Responsible for planning, implementation and evaluation of client’s plans of care for appropriateness to individual client needs
- Provide initial in-home evaluations and plan for and conduct team conferences and share in the responsibility of assessing clinical case management activities
- Establish and maintain positive relationships with government regulators, clients, families, other area health care providers, physicians and community at large
- Actively maintain up-to-date knowledge of applicable State and Federal laws and regulations and enforce and demonstrate compliance at all times
- Ensure the delivery of nursing services through assessment and supervision
- Report changes in the client’s medical or mental condition to the attending physician and Director of Clinical Services
- Additionally, facilitate and promote client and family in education to assist and promote return of optimal health status
- On an ongoing basis, participate in the continuing review of service and participation in the performance improvement program
RN, Quality Management
Tenet Health - Harbor Health Plan
Detroit, MI
06.2015 - 12.2015
- Under the direction of the Manager of Quality and the Director of Quality Management (QM), accountable for implementation, development and monitoring quality projects and programs (mainly to act as a liaison for the Medical Homes Initiative and assist with Early Periodic Screening Diagnosis and Treatment (EPSDT) operations)
- Worked closely within the QM Unit to develop and maintain a highly functioning quality organization characterized by teamwork, cooperation, efficiency, innovation and excellence
- Assist with clinical quality of care review process, the medical record audit process and analysis of data for presentation to appropriate health plan committees
- Work closely with the Network Management department to ensure provider compliance with requirements and best practices and also to ensure that all contract requirements are completed successfully and timely
- Responsible for leading condition specific work efforts focused on but not limited to preventative care efforts to improve the compliance to measured performance indicators of population health
- Perform ongoing root cause analysis of specific condition states, analysis of gaps in clinical care, barriers to care, assess care opportunities for member and provider action, design and implement member and provider specific interventions, track member and provider engagement responses, outcome achievement, analyze findings and improvement to quality of care
- Interact with members, providers and community agencies to ensure engagement with defined interventions
- Ensure all regulatory requirements are addressed per condition state
- Support the collection of HEDIS supplemental data for inclusion in the HEDIS Supplemental Database and assists with HEDIS Hybrid medical record review
- In conjunction with the HEDIS management team, ensure alignment of all interventions with the HEDIS Strategic Plan
RN, Case Manager
A-Line Staffing, Blue Cross Blue Shield of Michigan
Detroit, MI
10.2014 - 04.2015
- Manage caseload of 25+ members telephonically, providing educational and treatment plans by working with the member and / or designee in agreement with physicians, that will assure safe and cost effective quality of care
- Responsible for primary care, case management and medication management
- Support members with customized patient teaching tools
- Accurately document all elements of nursing assessment, treatments, medications, discharge instructions and follow-up care
- Maintain patient charts and confidential files
- Provide necessary health education training for patients
- Often commended for maintaining the respect and dignity of members
- Prepared for NCQA and JCAHO reviews by following quality care systems and standards, including but not limited to, creating and improving medical protocols / guidelines
RN, Case Manager, Home Healthcare Nurse
McLaren Homecare Group
Davison, MI
03.2014 - 06.2014
- Under minimal supervision, implemented the agency program of full time professional nursing service to patients in their homes in accordance with agency standards and policies
- Initiated and provided medically prescribed skilled nursing care and / or health counseling that contributed to the treatment of the medical condition, achievement of the rehabilitation potential, and reduction of pain and anxiety
- Made the initial visit to assess the patient's physical and emotional status, needs, and resources through observation, interview and analysis of records
- Prepared the nursing plan of care, in accordance with the physician's plan of treatment, based on problems identified in the nursing assessment and provided patient teaching using the Care Plan / Standard of Care
- Provided emotional support and encouragement to help the patient and family accept and adjust to the effects of disease or disability
- Notified physician and clinical supervisor of changes in patient condition
RN, Case Manager / Utilization Review
Expedient Medstaff – DMC, Sinai Grace Hospital
Detroit, MI
09.2013 - 01.2014
- Under limited direction and according to established policies and procedures, responsible for collaborating with physicians and applying medical necessity criteria to determine appropriate level of care at all points of entry
- Access location points to include emergency department, direct admits, procedural areas and surgery
- Coordinated the gathering of pertinent patient information from various sources for the purposes of pursuing insurance authorization or ensuring reasonable and necessary criteria are met
- Integrated Third Party payer agreement terms and interfaced with respective payer representatives to communicate information and submit clinical reviews
- On an ongoing basis, identified and made recommendations to continuously improve processes and create efficiencies, both with payers and internally
- Activated the physician secondary review process for medical necessity determination
- Analyzed case management outcome data to facilitate appeals and denials
- Maintained a working knowledge of the requirements of payers, regulatory and compliance entities
- Established and maintained effective relationships with physicians and all other staff members, internally and externally
Education
Bachelor Degree of Science - Nursing
University of Michigan, School of Nursing
01.2018
Associate Degree - Nursing
Oakland Community College
01.2005
Skills
- Patient advocacy
- Quality assessments
- Strong medical ethic
- Case conferencing
- Acute care
- Rehabilitative care
- Home health care
- Infection control standards
- Conflict resolution
- Relationship building
- Team building
- Cultural awareness
- Cultural sensitivity
- Personal integrity
- Professional integrity
- Training
- Development
- Health expertise
- Wellness expertise
- Utilization management
- Case management
- Case review
- Patient-oriented
- Public speaking
- Critical thinking
- Leadership
- Pediatric disease management
Certification
- Registered Nurse, Michigan, 4704250603
Timeline
RN, Utilization Management Nurse Coordinator
Aetna Better Health of Michigan
04.2024 - Current
RN, Care Manager
Aetna Better Health of Michigan
03.2022 - 04.2024
RN, Care Manager
Blue Cross Blue Shield of Michigan
09.2021 - 01.2022
RN, Clinical Supervisor
Maxim Healthcare Services
02.2016 - 09.2021
RN, Quality Management
Tenet Health - Harbor Health Plan
06.2015 - 12.2015
RN, Case Manager
A-Line Staffing, Blue Cross Blue Shield of Michigan
10.2014 - 04.2015
RN, Case Manager, Home Healthcare Nurse
McLaren Homecare Group
03.2014 - 06.2014
RN, Case Manager / Utilization Review
Expedient Medstaff – DMC, Sinai Grace Hospital
09.2013 - 01.2014
Bachelor Degree of Science - Nursing
University of Michigan, School of Nursing
Associate Degree - Nursing
Oakland Community College
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