MIRIAM M. LEDERER
Union
Summary
Results-oriented nursing leader with over 20 years of experience in managed care, home infusion, long-term care, utilization management, and acute care. Expertise in regional operations, clinical quality oversight, staff development, and regulatory compliance. Skilled in building high-performing teams, optimizing workflows, and enhancing quality indicators. Experienced in managing multidisciplinary teams, implementing telehealth transitions, and collaborating with state agencies and insurers.
Overview
1
1
Certification
45
45
years of professional experience
Work History
Senior Regional Nurse Manager, NYIA Project
Maximus Health Services East
New York
08.2020 - 11.2025
- Provided senior regional leadership in developing and guiding management teams to align operations with NYIA project objectives and DOH expectations.
- Directed regional quality oversight through medical record audits, supervisory evaluations, and performance-based quality reviews, ensuring compliance with NYIA project standards.
- Partnered with senior leadership to lead workflow redesign, improve documentation accuracy, strengthen operational performance metrics, and advance project priorities.
- Led escalation management for consumer grievances, implementing service recovery strategies that enhanced consumer experience and ensured regulatory compliance.
- Led project in partnership with the Independent Practitioner Panel to implement telehealth enhancements, including closed-captioning solutions for members with auditory deficits.
- Oversaw recruitment, hiring, training, and quarterly performance evaluations, aligning staff development with regional operational goals to enhance team effectiveness.
- Designed and implemented comprehensive RN training checklists to standardize onboarding, strengthen management readiness, and support leadership development.
- Represented regional leadership in interdisciplinary meetings and led program-wide process improvement initiatives to support consistency, efficiency, and project success.
Regional Nurse Manager, CFEEC
Maximus
New York
09.2019 - 08.2021
- Led and supervised a team of 1215 Nurse Evaluators responsible for conducting conflict-free Medicaid eligibility assessments.
- Directed quarterly supervisory visits across in-person and telehealth settings, ensuring consistent clinical oversight during pandemic operations.
- Developed education initiatives with case studies and training modules, enhancing evaluator competency and ensuring compliance with Medicaid standards.
- Partnered with Quality Assurance leadership to review denials, identify performance trends, and implement corrective action plans.
- Partnered with Quality Assurance leadership to review denial trends and implement corrective action plans, improving quality of Medicaid eligibility assessments.
- Managed timekeeping approvals, staffing schedules, and workflow coordination, enhancing daily performance reporting and supporting operational efficiency.
- Developed and delivered education initiatives using case studies and PowerPoint-based training modules to strengthen evaluator competency.
- Supported organization-wide telehealth conversion efforts by delivering staff presentations, training, and implementation guidance.
Manager of Care Managers
WellCare MLTC
New York
01.2019 - 06.2019
- Supervised 15 case managers, overseeing caseloads of approximately 85 MLTC members to ensure quality care delivery.
- Managed grievance and critical incident reporting processes in accordance with state quality assurance requirements.
- Conducted weekly audits of outreach documentation, person-centered service plan updates, UAS reviews, and authorization workflows.
- Managed grievance and critical incident reporting processes, ensuring compliance with state quality assurance requirements and enhancing care quality.
- Facilitated staff meetings to relay regulatory updates and operational priorities, fostering team alignment and effective workflow adaptation.
Utilization Nurse Case Manager, Personal Care
Anthem Managed Medicaid
New York
08.2017 - 12.2018
- Managed personal care service authorizations and Consumer Directed Personal Assistance Program (CDPAP) service requests.
- Promoted medically appropriate, high-quality, and cost-effective care by assessing medical necessity for inpatient admissions, extensions of stay, outpatient services, out-of-network services, treatment settings, and levels of care.
- Managed caseloads of 130-200 members, ensuring timely onboarding, effective care coordination, and completion of service authorizations.
- Assessed medical necessity for inpatient admissions, extensions of stay, outpatient services, and treatment settings to promote high-quality, cost-effective care.
- Conducted clinical assessments to identify individual needs, establish care goals, and develop individualized care plans.
- Reviewed UAS reports to support approval and denial determinations, and educated members on appeals processes.
- Utilized Facets to complete clinical documentation, member correspondence, and authorization workflows.
- Monitored and evaluated effectiveness of care management plans, modifying interventions to enhance member outcomes.
Clinical Evaluation Manager
VNS Choice FIDA
New York
05.2015 - 07.2017
- Managed high-volume caseloads of 120-200 members, ensuring effective complex care coordination.
- Led IDT meetings with members, caregivers, PCPs, and behavioral health teams.
- Reduced hospitalizations through proactive communication and HEDIS-focused education.
- Coordinated community-based services and secured authorizations for CBLTSS to enhance member support.
- Participated in behavioral health rounds and transitions-of-care committees.
- Advocated for members during grievance processes, collaborating with vendors to resolve issues effectively.
Manager of Care Managers
WellCare MLTC/DNSP
New York
05.2014 - 04.2015
- Managed telecommuting case managers overseeing caseloads of 7595 members to ensure quality care delivery.
- Assessed staff productivity by tracking attendance, ensuring case management compliance with DOH requirements, and analyzing member satisfaction outcomes to enhance service coordination.
- Performed compliance audits to ensure adherence to CMS and DOH regulatory requirements.
- Mentored new case managers, providing operational guidance on MLTC processes, service authorization requests, and grievance procedures to facilitate effective onboarding.
- Contributed to quality improvement initiatives designed to strengthen HEDIS performance and member outcomes.
Nurse Case Manager
WellCare Plans
New York
01.2013 - 05.2014
- Conducted monthly comprehensive health screenings, developing individualized care plans to address specific patient needs.
- Provided disease management education and reduced ER visits through proactive outreach.
- Authorized home care, DME, rehabilitation, and community services.
- Managed caseloads of 8095 members, documenting updates in EMMA to ensure accurate and timely patient information.
- Provided disease management education through proactive outreach, leading to a decrease in ER visits among high-risk patients.
Infusion Clinical Nurse Liaison
Home Infusion Specialty Company
New York
03.2012 - 01.2013
- Promoted growth of infusion business through strong relationships with hospitals, MLTCs, CHHAs, and insurers.
- Established on-site referral processes with hospital discharge planners and case managers, enhancing patient transition to home infusion.
- Completed clinical evaluations and coordinated home infusion services.
- Delivered educational presentations on home infusion benefits, Medicare/Medicaid criteria, and vascular access care.
- Delivered educational presentations on home infusion benefits, Medicare/Medicaid criteria, and vascular access care, improving understanding and utilization among healthcare providers.
- Evaluated new infusion products and collaborated with hospice and palliative care programs to enhance patient care options.
Nurse Case Manager
Jewish Guild for the Blind
New York
03.2010 - 03.2012
- Coordinated care with physicians and interdisciplinary teams, enhancing medication adherence and patient outcomes.
- Managed caseloads of 70-90 visually impaired members, completing MRT assessments and DOH-required summaries to ensure comprehensive care.
- Cultivated positive relationships with hospital staff, patients, and families to enhance communication and collaboration.
Patient Service Manager
VNSNY Home Infusion
New York
03.2003 - 09.2009
- Managed specialized infusion RNs and coordinators, enhancing care delivery in CHHA model.
- Collaborated with managed care departments on service authorizations and reimbursement.
- Expanded specialty services by obtaining PICC credentialing and implementing home chest X-ray programs.
- Expanded specialty services through PICC credentialing and implementation of home chest X-ray programs, improving patient access to necessary diagnostics.
- Led infection control initiatives and evaluated new vascular access and wound care products.
- Tracked IV catheter infection rates and implemented prevention protocols.
- Developed admission criteria using OASIS documentation.
- Cultivated relationships with hospitals, MD offices, infusion pharmacies, and insurers to facilitate patient care coordination.
- Established partnerships with hospitals, MD offices, infusion pharmacies, and insurers to enhance patient care coordination.
Business Development Home Care Consultant
VNSNY
New York
03.2001 - 03.2003
- Acted as on-site liaison at Memorial Sloan Kettering.
- Secured authorizations and promoted VNS services to hospital providers, enhancing patient transition to home care.
- Screened home care candidates and coordinated discharge planning.
- Secured necessary authorizations for patient services. and marketed VNS services to hospital providers.
Home Care Infusion Specialist
Mount Sinai Health System
New York
10.1997 - 12.2000
- Directed care management for CHHA clients, ensuring continuity of care from admission through discharge.
- Inserted peripheral vascular access devices including midlines and PICCs.
- Directed care management for CHHA clients from admission through discharge.
- Handled diverse client cases across Medicare, Medicaid, and managed care carriers.
- Participated in OBQI Medicare initiatives and home INR monitoring studies to enhance patient outcomes and treatment efficacy.
Nurse Clinician
Mount Sinai Health System
New York
10.1987 - 10.1997
- Collaborated with Nutritional Support, Infusion Education, and Vascular Access teams to improve patient outcomes.
- Developed vascular access protocols and delivered staff development presentations.
- Educated nursing units on TPN and enteral nutrition.
- Developed vascular access protocols and presented staff development sessions to improve staff competencies.
- Contributed to Nutritional Support, Infusion Education, and Vascular Access teams to enhance patient care.
- Presented at professional conferences and organized community health fairs to promote community health awareness.
Senior Clinical Nurse Supervisor, Surgical ICU
Mount Sinai Health System
New York
10.1986 - 10.1987
- Managed triage assignments and precepted new staff to ensure quality care and effective onboarding.
- Coordinated admissions, discharges, and staff scheduling to optimize patient flow and resource utilization.
- Delivered patient and family education while facilitating support groups to enhance understanding and emotional well-being.
- Improved unit policies and procedures to ensure compliance and best practices.
Surgical ICU Nurse
Mount Sinai Health System
New York
01.1981 - 10.1986
- Managed ventilators, tracheostomies, and complex postoperative patients to stabilize critical conditions.
- Conducted comprehensive assessments and advanced hemodynamic monitoring to ensure optimal patient outcomes.
- Implemented infection control protocols and collaborated with interdisciplinary teams to enhance patient safety.
Education
Bachelor of Science - Nursing
Hunter Bellevue School of Nursing
New York, NYSkills
- MLTC program management
- UAS-NY Assessments & DOH Compliance
- Clinical Care Coordination
- Transitions of Care Coordination
- Quality assurance
- Telehealth Program Development
- Regional Operations Leadership
- Staff management
- Regulatory compliance
- Interdisciplinary Team Collaboration
- Member advocacy
- Patient & Family Education
Certification
- Professional Registered Professional Nurse (RN) NY. N.J. Multistate compact license
- Previous certifications- CCRN, Nutritional Support , CRNI, CCM
EDUCATION
Professional proficiency in Spanish, including speaking, reading, and writing.
INTERESTS
Professional proficiency in Spanish, including speaking, reading, and writing.
Affiliations
Professional Affiliations ANA and NYSNA, NJSNA
Timeline
Senior Regional Nurse Manager, NYIA Project
Maximus Health Services East
08.2020 - 11.2025
Regional Nurse Manager, CFEEC
Maximus
09.2019 - 08.2021
Manager of Care Managers
WellCare MLTC
01.2019 - 06.2019
Utilization Nurse Case Manager, Personal Care
Anthem Managed Medicaid
08.2017 - 12.2018
Clinical Evaluation Manager
VNS Choice FIDA
05.2015 - 07.2017
Manager of Care Managers
WellCare MLTC/DNSP
05.2014 - 04.2015
Nurse Case Manager
WellCare Plans
01.2013 - 05.2014
Infusion Clinical Nurse Liaison
Home Infusion Specialty Company
03.2012 - 01.2013
Nurse Case Manager
Jewish Guild for the Blind
03.2010 - 03.2012
Patient Service Manager
VNSNY Home Infusion
03.2003 - 09.2009
Business Development Home Care Consultant
VNSNY
03.2001 - 03.2003
Home Care Infusion Specialist
Mount Sinai Health System
10.1997 - 12.2000
Nurse Clinician
Mount Sinai Health System
10.1987 - 10.1997
Senior Clinical Nurse Supervisor, Surgical ICU
Mount Sinai Health System
10.1986 - 10.1987
Surgical ICU Nurse
Mount Sinai Health System
01.1981 - 10.1986
Bachelor of Science - Nursing
Hunter Bellevue School of Nursing