Lori Martin
Holly Springs,NC
Summary
Continue my career with an organization that will utilize my nurse management, supervision, and administrative skills to benefit mutual growth and success.
Overview
31
31
years of professional experience
Work History
Senior Manager, Medicare Provider Appeals
Aetna/CVS Health
04.2022 - Current
- Responsible for oversight of Medicare Clinical Appeals associate managers, team leaders, and appeals nurse consultants
- Responsibilities include full spectrum appeals oversight including program description, departmental workflows, working job resources, Service Level Agreements, Policies and Procedures, reports, trainings, and other work projects as needed
- Communicate program status to Vice President, Clinical Operations and other Executives as needed
- Prepare Grievance & Appeals reports, as required by regulatory agencies
- Provide leadership and direction to staff in the G&A department
- Hire, coach, counsel, and evaluate performance of direct reports
- Lead continued development and implementation of an organizational grievance training program – regular training of departments and individual staff as required to assist in ensuring regulatory compliance
- Partner with departmental leaders to identify trends and improve operational processes that impact member and provider experience with the health plan and the provider network
- Provide guidance to Grievances & Appeals staff in the review, research, monitoring and routing of complaints, grievances and appeal cases to appropriate personnel to assure timely, comprehensive and documented resolution is achieved
- Work across departments to achieve full grievance and appeal resolutions
- Manage challenging and/or complex grievances and appeals that require escalation and continued evaluation
- Ensure that all information to providers, members, employees, and other appropriate persons is accurate, consistent and customer sensitive
- Participate in internal committee and interdisciplinary meetings, reporting recent activity and analysis of trends, and makes recommendations for problem resolution and performance improvement
- Set and hold accountable standard protocols, processes, and policies
- Perform other duties, projects and actions as assigned.
Associate Manager, Utilization Management
Aetna/CVS Health
01.2020 - 04.2022
- Responsible for oversight of acute UM nursing team
- Work closely with territory leadership team and manager to ensure team is working at high level of productivity, while adhering to all clinical policies and procedures
- Collaborate and deliver department training
- Responsible for recruitment and hiring process for staff
- Collaborate daily, weekly, and monthly with leadership and individual team members to review productivity and census reporting to ensure regulatory standards and timelines are met
- Assess developmental needs and collaborate with others to implement action plans that support development of high performing team members
- Lead team members to embrace change
- Create a positive work environment while holding each team member accountable to compliance policies and procedures.
Nurse Consultant, Utilization Management
Aetna/CVS Health
09.2017 - 12.2019
- Gather clinical information while applying the appropriate clinical criteria, guidelines, and policies to render coverage determinations for continued care
- Communicate with providers and outlying facilities regarding patient/care and treatment
- Identify areas for member referral opportunities to integrate other products, services and/or programs to promote quality effective healthcare
- Utilize my clinical skills to coordinate, document and communicate all aspects of utilization management including precertification, predetermination, concurrent review, retro review, and enhanced discharge planning activity to members while adhering to productivity and quality expectations.
Nurse Manager, Communications Center
Rochester Regional Health System
07.2015 - 08.2017
- Functioned as Clinical Nurse Manager for Rochester Regional Transfer Center, Discharge Call Center and Rochester Regional Clinical After-Hours Triage
- Responsible for problem solving, providing clinical expertise, and facilitating staff mentoring and coaching
- Worked independently to facilitate day-to-day operations of the call center in decision making, communications and problem-solving techniques
- Work closely with executive leadership, providers, nurses, and other members of the health care community to effectively navigate and manage patient care experience - providing consistent continuity of care through our health system
- Participated in department/system committees and disseminate information to team members.
RN, Communications Center
Rochester Regional Health System
09.2009 - 07.2015
- Functioned as Clinical Nurse Manager for Rochester Regional Transfer Center, Discharge Call Center and Rochester Regional Clinical After-Hours Triage
- Responsible for problem solving, providing clinical expertise, and facilitating staff mentoring and coaching
- Worked independently to facilitate day-to-day operations of the call center in decision making, communications and problem-solving techniques
- Work closely with executive leadership, providers, nurses, and other members of the health care community to effectively navigate and manage patient care experience - providing consistent continuity of care through our health system
- Participated in department/system committees and disseminate information to team members.
RN Level III, Pediatric Triage
Strong Memorial/Rochester General Hospital - Community Pediatric Telephone Triage
08.2001 - 09.2009
- Provided emergency after-hour assistance for patients of over 200 pediatricians in the New York, New Jersey, Michigan, and Wisconsin area
- Responsible for triage of all emergency calls
- Instruct parents/caregivers on a wide range of healthcare, developmental and behavioral issues
- Communicate with physicians regarding emergency patient care
- Process all calls via PC utilizing McKesson software application.
RN Level III, Allergy/ENT
Strong Memorial Hospital/Otolaryngology Clinic
01.2004 - 01.2008
- Oversee administration of pediatric patient sedation
- Monitor and treat sedation complications
- Assisted in ABR testing procedures
- Administer/monitor allergy patient response to allergy injections and provide support
- Responsible for mixing serum for all existing allergy patients
- Provide triage support to allergy and ENT patient calls
- Plan, implement, and perform chart audits for quality improvement
- Provide telephone triage for varied patient population.
- Provide ENT patients with pre-op and post-op instruction and support
- Assisted physicians with in-office procedures
- Arranged direct admissions from out-patient clinic to hospital, as requested by physician(s)
- BLS and PALS certified.
RN
Fairport Pediatrics
10.1999 - 05.2004
- Assisted physicians with patient care by performing various medical procedures
- Responsible for assessing patients and knowledge recall of various disease processes
- Administered immunizations, medications, and allergy injections
- Provide telephone triage.
Sales Manager
Medi Phone
01.1994 - 08.1999
- Responsible for eight full-time sales associates, including hiring, training, and reviewing team members
- Responsible for acquiring new medical call center accounts and maintaining existing accounts
- Maintained production logs, including sales for each territory and customer care data.
RN Level II, Cardiovascular Intensive Care
Lutheran Hospital of Fort Wayne, IN
01.1993 - 02.1994
- Responsible for aggressive clinical care of patients directly from the operating room following heart transplants and cardiovascular surgery
- Administered medication and performed various medical procedures for complete up-to-date care of patients
- Consulted with physicians regarding patient care, present treatment, and patient care plan.
Education
Bachelor of Science in Nursing -
St. John Fisher College
Associate of Science in Nursing -
University of St. Francis
Bachelor of Science – Business/Psychology -
Indiana University
Skills
- Clinical Leadership
- Interdisciplinary Collaboration
- Quality Improvement
- Workflow and Patient Management
- Healthcare knowledge
- Process improvement strategies
- Critical thinking abilities
- Written Communication
- Organizational Skills
- Strategic Planning
References
Available upon request.
Timeline
Senior Manager, Medicare Provider Appeals
Aetna/CVS Health
04.2022 - Current
Associate Manager, Utilization Management
Aetna/CVS Health
01.2020 - 04.2022
Nurse Consultant, Utilization Management
Aetna/CVS Health
09.2017 - 12.2019
Nurse Manager, Communications Center
Rochester Regional Health System
07.2015 - 08.2017
RN, Communications Center
Rochester Regional Health System
09.2009 - 07.2015
RN Level III, Allergy/ENT
Strong Memorial Hospital/Otolaryngology Clinic
01.2004 - 01.2008
RN Level III, Pediatric Triage
Strong Memorial/Rochester General Hospital - Community Pediatric Telephone Triage
08.2001 - 09.2009
RN
Fairport Pediatrics
10.1999 - 05.2004
Sales Manager
Medi Phone
01.1994 - 08.1999
RN Level II, Cardiovascular Intensive Care
Lutheran Hospital of Fort Wayne, IN
01.1993 - 02.1994
Bachelor of Science in Nursing -
St. John Fisher College
Associate of Science in Nursing -
University of St. Francis
Bachelor of Science – Business/Psychology -
Indiana University