Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Sandra Giove-Roman

Hazlet,New Jersey

Summary

Experienced with clinical case management, consistently ensuring seamless patient care coordination across various healthcare settings, including managed care. Utilizes strong communication and problem-solving skills to address patient needs and streamline care plans. Knowledge of healthcare regulations and patient advocacy to enhance care outcomes and support client well-being.

Overview

11
11
years of professional experience
1
1
Certification

Work History

Clinical Case Manager (Clinical Operations)

Alight Solutions
06.2023 - Current
  • Facilitates medically sound decisions, carrying a caseload of 75-100 claims to ensure absence and disability claims are administered effectively and delivered compassionately to employees of a high-touch/high-profile financial firm.
  • Present cases to a panel that includes multidisciplinary teams in roundtable discussions, which requires dynamic communication, critical thinking, negotiation skills, holistic case conceptualization, and active case management planning.
  • Coordinate multidisciplinary teams to facilitate effective communication and service delivery.
  • Assist employee/client in making informed choices via patient advocacy in alignment with Medical Disability Guidelines (MDG) and employer-based benefit plans and /or laws regulating disability management.
  • Recognize and identify opportunities to improve the quality of care/services and initiate steps and activities to advance outcomes.
  • Act as a liaison between all parties required in case management to facilitate continuous communication and consensus.
  • Facilitate engagement with firm resources, such as the Employee Assistance Program and Critical Health Solutions, to support employees' overall health and wellness.

Manager, ICM (Clinical Operations)

Horizon Blue Cross Blue Shield
07.2022 - 06.2023
  • Led a cross-functional team of 87 to enhance operational efficiency and streamline workflows.
  • Resolved staff member conflicts through actively listening to concerns and finding an appropriate middle ground.
  • Cross-trained existing employees to maximize team agility and performance.
  • Developed a strong company culture focused on employee engagement, collaboration, and continuous learning opportunities.
  • Streamlined workflows by identifying bottlenecks in existing systems and implementing appropriate solutions.
  • Mentored staff, fostering professional development and improving team productivity.
  • Spearheaded process improvement initiatives, resulting in enhanced service delivery and client satisfaction.
  • Managed budgeting activities, aligning financial resources with strategic priorities for optimal impact.
  • Facilitated team brainstorming sessions that led to innovative solutions for long-standing operational challenges.
  • Coordinated with the IT department to upgrade technology infrastructure, enhancing operational efficiency and data security.
  • Recruited, interviewed, and hired employees and implemented a mentoring program to promote positive feedback and engagement.
  • Defined clear targets and objectives and communicated them to other team members.
  • Established performance goals for employees and provided feedback on methods for reaching those milestones.
  • Monitored audit scores and trends to ensure quality and adherence to regulatory guidelines established by NCQA, DMHAS, CMS, and DOBI.
  • In the Director's absence, effectively represented the department.
  • Conducted annual compensation reviews for staff, taking into account goal achievement and progress toward compliance and best practices.

Supervisor MLTSS MDC/PCA

Horizon Blue Cross Blue Shield
06.2019 - 07.2022
  • Managed a team of 16 field Registered Nurses spanning over 7 New Jersey Northern Counties in a fast-paced work environment.
  • Supported safe discharge planning through the timely deployment of staff to evaluate members' needs through NJ Choice assessment tool outcomes.
  • Supervised daily operations, ensuring adherence to safety protocols and operational standards.
  • Completed revision of field assignments as needed based on regional membership, while maintaining fiscal responsibility.
  • Conducted performance evaluations, providing constructive feedback to improve individual and team performance.
  • Attended Medical Fair Hearings as an expert witness, which involved testifying and providing clarity on State guidelines and regulations as they pertain to the MDC/PCA tool outcomes; collaborating with Horizon Legal Counsel to negotiate outcomes when appropriate.
  • Collaborated with Horizon New Jersey Health providers to ensure quality of care and troubleshoot authorization issues as needed.
  • Developed training programs, enhancing staff knowledge and improving service delivery.
  • Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
  • Enhanced communication within the team by holding regular meetings and encouraging open dialogue among all team members.
  • Conducted performance evaluations for staff members, identifying areas of improvement and guiding professional development plans.
  • Analyzed operational metrics, identifying trends to inform strategic decision-making processes.
  • Successfully obtained NJ Choice certification.

RN II On Call Per Diem Staff

Horizon Blue Cross Blue Shield
01.2016 - 08.2021
  • Worked autonomously to meet regulatory requirements by ensuring navigation of discharge planning after hours.
  • Applied Utilization Management processes to evaluate appropriateness, efficiency, and medical necessity for treatments, services, procedures, and facilities requested for members on a case-by-case basis.
  • Navigated multiple systems to confirm benefits, policies, and eligibility.
  • Collaborated with the Medical Director on call, as needed, for determinations.
  • Documented as required using Care Radius as the medical management platform.

RN II Primary Nurse Case Manager

Horizon Blue Cross Blue Shield
11.2014 - 07.2019
  • Skilled at working autonomously in a remote environment.
  • Exhibited expertise in Case Management/Disease Management standards of practice, as evident by proficient outcomes through monthly case audits and routine evaluations.
  • Educated members on disease process and supported navigation of their health care benefits to ensure improved member outcomes through efficient and effective utilization.
  • Experienced in Utilization Management, conducting thorough review of clinical data against guidelines (MCG and Med Pol) to determine outcomes.
  • Collaborated with Medical Directors as needed to ensure appropriateness of determinations.
  • Demonstrated working knowledge of State mandates, regulations, health care systems, documentation, and accreditation standards to include NCQA, DOBI, DMAHS, and CMS.
  • Developed new staff training program focused on clinical skills and regulatory standards, enhancing team knowledge and performance, as well as patient satisfaction.
  • Mentored new nursing staff, contributing to a supportive work environment and improved retention rates.

Education

Bachelor of Science - Nursing

New Jersey City University
Jersey City, NJ
01.2019

Skills

  • Teamwork and cooperation
  • Healthcare navigation
  • Clinical documentation
  • Clinical assessment
  • Care coordination
  • Recruiting and interviewing
  • Discharge planning
  • Utilization review
  • Multidisciplinary collaboration
  • Problem-solving
  • Time management
  • Critical thinking
  • Clear communication

Certification

  • Registered Nurse State of New Jersey
  • Certified Case Manager
  • Sigma Theta Tau Nursing Honor Society

Timeline

Clinical Case Manager (Clinical Operations)

Alight Solutions
06.2023 - Current

Manager, ICM (Clinical Operations)

Horizon Blue Cross Blue Shield
07.2022 - 06.2023

Supervisor MLTSS MDC/PCA

Horizon Blue Cross Blue Shield
06.2019 - 07.2022

RN II On Call Per Diem Staff

Horizon Blue Cross Blue Shield
01.2016 - 08.2021

RN II Primary Nurse Case Manager

Horizon Blue Cross Blue Shield
11.2014 - 07.2019

Bachelor of Science - Nursing

New Jersey City University

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