Nichol Foss
Assistant Manager, Clinical Operations
Jay,Maine
Summary
Accomplished Assistant Manager ready to offer exceptional leadership, advocacy and strong knowledge base to assist with operational successes to the current role as a Supervisor in Utilization Management position. Forward thinker, problem solver and effective communicator. Strong organizational skills, analytical skills and success with improving processes to assist with maximizing team productivity.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Assistant Manager, Clinical Operations
COMMUNITY HEALTH OPTIONS
Lewiston, Maine
03.2020 - Current
- Oversight of effective and efficient day-to-day operations of Utilization Management as well as Medical and Benefit Appeals in accordance with NCQA Standards, State and Federal regulations.
- Assist with adverse determination correspondence to ensure appropriateness of decision remain compliant with regulations.
- Support professional development of individuals with personalized goal development and plans for achievement.
- Apply strong working knowledge of evidence-based clinical guidelines, Health Plan benefits and clinical claims review.
- Monitor individual team member performance and provide mentoring and coaching as needed to promote consistent adherence to standards, shared ownership of quality outcomes.
- Oversight of Utilization Management concurrent review authorizations, Medical and Benefit Appeals including workflows, processes, team support, division, and organizational goals.
- Create and extract data from reports for analysis of Utilization Management inpatient length of stay and readmissions.
- Oversight of cross-functional collaboration to fulfill organizational needs including all aspects of Utilization Management, Care Management, High Dollar Bill Audit Review, Claim Reconsideration's, Appeals coverage, Medical Management claim appeal reviews, and denial letter coverage.
Clinical Specialist
COMMUNITY HEALTH OPTIONS
Lewiston, Maine
04.2015 - 03.2020
- Acknowledge, research, and assist in resolution of benefit and medical appeals.
- Assist in oversight of appeals processes, team support, organizational goals.
- Team, division, and organizational goals.
- Perform appeal audits ensuring NCQA and regulatory requirements are met.
- Assist with adverse determination correspondence to ensure appropriateness of decision remain compliant with regulations.
- Support professional development of individuals with personalized goal development and plans for achievement.
- Performed concurrent, prospective, and retrospective reviews of provider requested health services to ensure they are medically necessary, evidence-based and delivered in the most effective health care setting.
Registered Nurse
RUMFORD HOSPITAL
Rumford, Maine
05.2008 - 05.2016
- Broad patient experience including all Intensive Care, Emergency Department, Medical Surgical, and supervisory roles.
Swing Bed Coordinator
RUMFORD HOSPITAL
Rumford, Maine
05.2011 - 05.2015
- Development and Management of the Swing Bed program, ability to coordinate care with physicians, nursing, therapies and patients.
- Care coordination, Utilization management, and Discharge planning for all members with commercial, state, and federal payers.
- Write and maintain policies, procedures per Medicare Guidelines.
- Initiate education and provide policies and structure for safe patient handling program, including bariatric population trainings.
- Utilization Management coverage for entire inpatient unit.
Education
Bachelor of Science - Nursing
University of Maine At Fort Kent
Fort Kent, ME05-2016
Associates - Applied
Central Maine Medical Center- School of Nursing
Lewiston, ME05-2008
Master of Science -
Western Governors University
Salt Lake City, UTSkills
- Work efficiently in high pressure environments
- Detail oriented, Attentive, Quick learner
- Effective communicator with excellent critical thinking skills
- Strong knowledge of MCG Guidelines
- Experience in leadership roles and middle management
- Discharge planning, Case management, and Transitions of Care experience
- Oversight of operations and staff management
Certification
Care Guidelines Specialist Certification in Utilization Management
Timeline
Assistant Manager, Clinical Operations
COMMUNITY HEALTH OPTIONS
03.2020 - Current
Clinical Specialist
COMMUNITY HEALTH OPTIONS
04.2015 - 03.2020
Swing Bed Coordinator
RUMFORD HOSPITAL
05.2011 - 05.2015
Registered Nurse
RUMFORD HOSPITAL
05.2008 - 05.2016
Bachelor of Science - Nursing
University of Maine At Fort Kent
Associates - Applied
Central Maine Medical Center- School of Nursing
Master of Science -
Western Governors University
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