Sabrina Summers
Roosevelt,N.Y.
Summary
A career opportunity in a progressive health care environment that enables me to utilize my diversity to impact the outcome of patient-related services. Talented Case Manager adept at handling high caseloads without sacrificing quality of care. Operates in high-pressure environments while recommending best resources and courses of action to benefit patient needs and return each to optimal quality of life.
Overview
26
26
years of professional experience
Work History
Case Manager, Medical Management
Healthfirst
03.2011 - Current
- Provides case management services for assigned member caseloads which include:
- Pre-certification – performing risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual/MCG criteria
- Assessment - identifying medical, psychological, and social issues that need intervention
- Documenting - documenting all determinations, notifications, interventions, and telephone encounters in accordance with established documentation standards and regulatory guidelines
- Assists in identifying opportunities for and facilitating alternative care options based on member needs and assessments
- Prepare cases for Medical Director Review
- Occasional overtime as necessary
- Additional duties as assigned
- Ability to work independently, maintain a working knowledge of all job aids, policies, and regulations
Utilization Review / Pre-Auth Nurse
Elderplan Inc.
08.2006 - 03.2011
- Work as a team member and facilitate communication among the members 65 years and older, healthcare providers, community and medical management staff
- Operate in Medical Management Department to conduct reviews for medical services that require pre-authorization prior to treatments
- Evaluate the proposed treatment plan and determine if care is medically necessary
- Identify alternative of care and refer cases to Case Management
- Coordinates utilization of resources within Medicare guidelines and benefit parameters, as well as discharge planning needs, through communication with attending practitioners, primary care physicians, discharge planners, social workers, utilization managers, vendors, the supervisor of Utilization Management, and Care Management Staff
Interdisciplinary Care Team Monitor
Elderplan Inc.
02.2001 - 08.2006
- Screen all incoming calls and obtain appropriate information from members/providers when pre-certifying a hospital admission and/or other Coordinated Care products
- Document all admission requests in appropriate system and refer them through the system to appropriate interdisciplinary team members
- Collaborate with physicians, providers, vendors and medical facilities to collect and coordinate pharmaceutical benefits
- Make post hospital calls to members upon discharge from the hospital to ensure continuity of care
- Handle inbound and outbound calls related to service problems such as chronic care benefits/benefit status and attempts to resolve issues
- Identify issues related to Member Services, Provider Services, Enrollment or Claims Departments and refer them to the appropriate department for resolution
- Trained up to 15 employees throughout tenure
- Facilitate the ordering of DME and medical supplies for members in conjunction with the Care Plan and Provider request
- Participate in all Care Management team meetings and discussed social issues and resolution
- Promoted to Utilization Review Nurse
Pre-Authorizations Coordinator
Elderplan Inc.
06.1998 - 02.2001
- Processed requests for specialty care and other services such as medical equipment, medical supplies and transportation services from network and out of network providers in accordance with departmental criteria and guidelines
- Documented all hospital admission requests in appropriate systems such as Amisys and Active Health Management Applications and referred them through the system to Utilization Management Coordinators
- All requests and telephone encounters with providers and members were documented in the appropriate systems to ensure integrity of data and members records
- Promoted to Interdisciplinary Care Team Monitor
Education
License Practical Nurse -
Borough of Manhattan Community College
01.2006
Skills
- Managed care
- Case management
- Identifying alternative care options
- Discharge planning
- Interqual knowledge
- Milliman knowledge
- CMS regulations
- NYSDOH regulations
- Clinical work experience
- Outlook
- Word
- Excel
- PowerPoint
- Adobe Acrobat
- Professional writing
- Electronic documentation
- Assessment skills
- Active listening
- Problem-Solving
- Case Management
- Case Documentation
- Organization and Multitasking
- Documentation And Reporting
- Decision-Making
- Relationship Building
References
References furnished upon request
Accomplishments
Assisted in the training of new Case Managers
Timeline
Case Manager, Medical Management
Healthfirst
03.2011 - Current
Utilization Review / Pre-Auth Nurse
Elderplan Inc.
08.2006 - 03.2011
Interdisciplinary Care Team Monitor
Elderplan Inc.
02.2001 - 08.2006
Pre-Authorizations Coordinator
Elderplan Inc.
06.1998 - 02.2001
License Practical Nurse -
Borough of Manhattan Community College
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