Ruth Marcellus

● Monitors audits and reports on departmental performance, presents dashboards for executive leadership review.

● Ensures availability of necessary tools and resources for the efficient management and coordination of patient care.

● Collaborates with physician leadership, nursing, and social work leadership to develop strategies, formulate plans, and implement interventions based on patient needs and clinical resources.

● Collaborates with Patient Financial Services, HIM, and CDI leadership to optimize revenue cycle. Builds strong collaborative working relationships with counterparts within CNE/lntegra, payors, and continuum and community service providers.

● Directs and coordinates payor utilization issues.

● Collaborates with designated Physician Advisor in program design and implementation, as well as day-to-day case activities.

● Develops and manages the department budget. Identifies, generates and implements cost containment initiatives within the department.

● Interviews and selects staff, ensuring new staff receives adequate training. Performs annual performance evaluations and effectively handles discipline issues. Assesses staff's ability to assess, manage and analyze the patient's total care needs and develop coordinated implementation plan to meet those needs.

● Preserves and protects patient and staff rights for confidentiality.

• Demonstrate strong hands on leadership
• Promote a positive work environment and ensure a high quality patient outcomes
• Oversight of all case management activities across the hospital inpt and obs
• Supervise a team of Case Managers RN/LSW, working collaboratively to enhance care coordination
• Expedite discharge planning and facilitate utilization review

● Run criteria for ED admissions

● Speak w/ED Physician for transfer of care secondary to non par insurance

● Meet w/patient and family members to discuss DCP needs

● Coordinate w/MSW for community based services & placement issues

● Criteria based reviews using both Milliman and Interqual for LOC

● Meeting with patients/family to discuss discharge planning needs

● Discharge planning for home w/services vs SNF or Rehab placement

● Facilitated member access to community based services & referrals to those organizations

● Actively participated in integrated team care management plan

● Proficient with Epic/AllScripts

● Supervise the daily operations of the UM staff and onsite review

● Ensure appropriate usage of resources in order to facilitate the UM process

● Ensure compliance w/state programs/P&P as well as analyze/recommend enhancements

● Educate staff to ensure consistent performance and adhere to daily workflow & standards

● Assist w/ensuring data collection to achieve corporate metric

● Improved member outcome by coordinating services w/Primary Care Physicians and other disciplines

● Decreased member length of stay in hospitals by accessing necessary providers for members healthcare

● Developed plan of care by utilizing assessment skills and discretionary judgment

● Facilitated member access to community based services & referrals to those organizations

● Actively participated in integrated team care management plan

● Onboarding Preceptor for new MMA personnel by shadowing for competencies and practicum

● Implemented member outreach during hospitalization for d/c planning & Transition of care needs

• Resolved conflicts between staff members or between staff members and patients and families in a professional manner.
• Maintained safety protocols and infection control measures to safeguard patients and medical staff.
• Ensured that all necessary supplies were available in order to provide high-quality care for patients in their homes.
• Facilitated communication among staff members across various departments within the organization.
• Collaborated with medical professionals to develop individualized treatment plans for patients based on their needs.
• Assisted with recruitment efforts by conducting interviews with potential candidates and making hiring decisions.
• Conducted regular meetings with staff members to discuss performance issues and identify areas for improvement.

• Communicated effectively with payers, providers, and members regarding authorization status and service denials.
• Interpreted clinical data from medical records and applied evidence-based criteria in order to make decisions regarding the appropriateness of care provided.
• Provided feedback on utilization management cases to providers as needed.
• Identified opportunities for improvement in health plan operations through analysis of utilization trends and outcomes.
• Reviewed requests for prior authorization by gathering pertinent information from medical records, insurance policies, and provider notes, in order to make an informed decision about treatment plans.
• Conducted initial reviews of medical records to determine appropriateness of requested services.
• Evaluated patient charts for accuracy, completeness, and compliance with established standards.

• Collaborated with physicians, nurses and other healthcare professionals to ensure optimal patient outcomes.
• Coordinated medical services between primary care providers, specialists, hospitals and outpatient clinics.
• Developed discharge plans for patients transitioning from acute care settings to home or alternate facilities.
• Educated patients on disease prevention strategies, wellness promotion techniques and lifestyle modifications.
• Actively participated in multidisciplinary rounds discussing complex cases with members of the healthcare team.
• Communicated regularly with family members regarding patient care needs and progress toward goals.
• Ensured compliance with regulatory standards concerning utilization review, ethical decision making and legal aspects of case management practice.
• Reviewed clinical data including lab results, radiology reports and vital signs to assess appropriateness of treatments.