Michelle Bauer -BSN, RN, CCM

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

• 24 reviews per day
• Recognized for 11 impact award for collaboration for identification and proactive planning for discharge planning to help meet Plan Targets and teamwork.

Collaborate by assessing, planning, facilitating, coordinating, evaluating, and advocating for option and services to meet an
individual’s and family’s comprehensive health needs through communication and available resources to promote member
safety, quality of care and cost-effective outcomes.
• Promoted to Senior level Case Management within 11 months of hire and received highest performance rating.
• Engaged and closed gaps with members by conducting Pre-admission calls, Inpatient Advocacy Outreach, and Post
Discharge Calls with a 95% increase in engagement and a 134% increase in Gap Closure savings in 2020.
• Empowered individual health and cost containment with Commercial Insurance by utilizing telephonic nursing skills with a
133% increase in High-Cost Claimant engagement in 2020.
• Collaborated with interdisciplinary teams, optimizing member outcomes to close gaps on community and financial
resources for members overall health with a 126% increase in referrals in 2020.
• Collaborated with Utilization Management on discharge planning and authorization review on active cases to be able to
stay within compliance of review.

Execute closing member gaps to prevent readmission. Collaborate with Physicians, Pharmacists, health care providers,
utilization management, and Social Workers to meet member needs. Advocate and empower members to review rights and
benefits.
• Engaged and closed gaps with members by conducting highly successful outgoing and support calls post discharge.
• Empowered individual health and cost containment with Medicare Advantage by utilizing telephonic nursing skills.
• Achieved average of 11 patient touches per day with goal of 8 by directing post discharge assessments.
• Collaborated with interdisciplinary teams, optimizing member outcomes to close gaps on community and financial
resources for members overall health.
• Educated members by utilizing Humana Health wise information on disease management and appropriate HEDIS
measures.

Personal Nurse Navigator, St. Petersburg, FL
2014 - 2017
Engaged and retained members with Medicare and Medicaid dual plan. Educated and assisted members, families, and promoted self-care activities. Coordinated with Primary Care Provider for HEDIS Stars.
• Promoted individual health and cost containment with Medicare / Medicaid members by utilizing telephonic nursing skills
for education, transportation, identifying barriers.
• Served as Team Lead and facilitated team meetings, as the point person under the Manager verify policies and work flow.

• Managing projects for project redesign for cost savings.

Examined utilization management for admission and recertification for skilled care for members with Medicare, Medicaid,
Commercial, or Tricare Insurance. Administered direct and indirect evaluations regarding competencies for employed staff.
Facilitated orientation for new hires and skills testing. Worked in nurse triage using on call system. Completed chart audits for
quality assurance.
• Targeted inefficiencies, increased safety in home, and prevented patient transfers to hospital by being part of Elite 100
Home Health Agencies in Nation.
• Lead and implemented electronic charting, selection of technology and equipment for, and designed competency-based training
program for multiple levels of care delivering under budget, establishing competency-based training program multiple
levels such as Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and Home Health Aides.