Sayuri "Sigh" Yamasaki
Summary
Registered Nurse with over 10yrs extensive experience in both Administrative and Clinical Nursing across Hospital and Insurance sectors. Expertise in integrating hospital and insurance processes to enhance operational efficiency. Demonstrated leadership in case management, utilization review, and denial/appeals management, with a strong background in Home Health, ER, and ICU settings. Experience includes roles at Honor Health, Memorial Hermann, UTMB, Parkland Memorial, and major insurance providers like Humana, Aetna, and United Healthcare.
Overview
41
41
years of professional experience
1
1
Certification
Work History
RN-Transitional Care Management
HONOR HEALTH
01.2019 - Current
- The transitional care model (TCM) of health care aims to reduce disruption in care and thus lower the chances of patients relapsing and having to return to the hospital.
- Focus on supporting patients during transitions between different healthcare settings, such as from a hospital to home- or Facility to Facility to ensure a smooth and safe transition, providing continuity of care and addressing potential gaps in care.
- Nurse-Led Interventions: focuses on helping older adults transition between healthcare settings and providers.
- Emphasize collaboration between nurses, physicians, and other healthcare professionals to ensure a coordinated approach to care.
- Auditing and reviewing charts, contacting insurance plans, obtaining prior authorizations.
- Nurse Helpline: Registered Nurses handle a high volume of phone calls in a multichannel center. These calls are inbound (incoming from various sources) or outbound (made by Honor Health to clients). Call centers play a crucial role in providing provider support, and other related services.
- Key functions are answering questions, resolving escalated issues, and providing guidance. Communicating important information in emergency situations.
RN-Case Manager
MEMORIAL HERMANN HOSPITAL SYSTEMS
Houston
01.2015 - 01.2019
- Responsible for performing case management for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating the optimization of patient’s/member’s healthcare across the care continuum.
- Conducts thorough/objective evaluation of patient’s status including physical, psychosocial, environmental, vocational, financial, and health status.
- Ensures member access to services appropriate to their health needs.
- Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangement.
- Interfaces with Medical Directors and Physician Advisors on the development of case management treatment plans; including physician care rounds.
- Negotiate rates of reimbursement, as applicable.
- Assists in problem solving with internal and external resources, providers, claims, and service issues.
- Perform duties telephonically.
- Assists with development of policies and procedures and process improvements.
Sr. Nurse Auditor, Clinical Denials & Appeals, Charge Capture RN
Honor Health
10.2005 - 12.2016
- Assesses the need for formal appeals of all clinical denials including but not limited to pre-authorization of diagnostic and surgical procedures, admissions, and for retroactive recovery reviews regarding medical necessity and limited billing compliance.
- Clinically validated the medical appropriateness and coding accuracy of services rendered for in and outpatients.
- Served as clinical resource and lead in the denials and nurse auditor department.
- Prepares documentation (appeal letters that are specific, concise, and conclusive; providing payers with appropriate clinical documentation that supports the findings. Adheres to all appeal timelines as prescribed by payer agreements.
- Evaluates and adheres to clinical and billing policies, guidelines and regulations of both commercial and governmental payers. Also, appeals denials or instructs the resubmission of claims based on compliant medical record documentation and hospital policies and procedures. Extensive working knowledge with RAC and coding validation.
- Performs medical documentation review and bill audits and resolves charge capture inquiries initiated by patients and insurers as needed. Ensuring compliance with third party pay guidelines and working closely with all management and staff throughout the revenue cycle to ensure appropriate, complete and timely charge entry and supporting medical record documentation.
- Maintains data and assists with identifying patterns of denial activity. Monitors payer response to appeal activity. Interacts with Utilization Management and other clinical departments to coordinate information for preparation of appeals and with Patient Financial Services in support of collection activities and/or in support of RAC activity contracted to outside physician advisors.
Director of Clinical Services & Pharmacy Protocol Program
Interface EAP
01.2002 - 10.2005
- Managing daily operations of clinical staff. Insuring policies and procedures are implemented.
- Contract negotiations with providers, ancillary facilities, and hospitals regarding rates and service of levels of care that include Acute, Sub-Acute, Residential, PHAP, and IOP.
- Client liaison for complaint escalation and resolution.
- Developed business strategies/requirements and analyze business objectives to increase revenue and productivity.
- Created an environment that is client driven where teamwork is paramount.
- Assisted in developing an annual market assessment, budget and business plan.
- Coordinate potential patient assessments prior to case acceptance.
- Conduct surveys to ensure quality of service.
- Direct staff recruitment/development activities and conduct ongoing skill evaluations.
- Developed CRM (Customer Relationship Management) program.
- Managed our Quality Assurance & Risk Management programs.
- Review and audited quality of data.
- Assisted in IT issues and implementations of new providers and services, HIPPA certification, URAC experience, JCAHO, NCQAA.
- HR Certified in process and procedures for recruiting and labor laws (State/Federal).
Sr. Case Manager & Utilization Review Nurse / Charge Capture and Nurse Auditor
Staff Search Incorporated
01.2002 - 01.2004
- Contract positions in Case Management, Utilization Review, Charge Capture, and Nurse Auditor functions.
- Managed Quality Assurance and Risk Management programs.
- Clinical and Operational management.
- Medical records and Charge Capture Audits.
- Analysis of potential problems, LOS-length stay using company guidelines.
- Self-Starter and work independently.
- Managed patients cost-effectively and promote the optimal patient outcome.
- Responsible for providing expedient/appropriate inpatient care.
Contracts and Order Administration Representative
Aspen Technology INC.
01.2000 - 01.2001
- Insured contract specifications were accurate per client request for software services and products.
- Generating and verification of accounting reports and budgets were on target.
- Executive Assistant to Director of Customer Relations and Management Team & Director of Global Training Department.
- CRM Customer Relations Team: Administrative duties, presentations, expense reports, calculating hours, and accounting issues for the team.
- Processed monthly & quarterly accounting reports and coding cost center and expense codes.
- Answered multiple telephone lines, arranged travel.
- GTD Global Training Department: Assisted director with international clients with training & support. Administrative duties, presentations, expense reports, calculating hours, expense reports and accounting issues for the team.
RN Case Manager-Utilization Review
Spring Branch Medical Center
01.1998 - 01.2000
- Directed quality assurance and risk management efforts to elevate patient safety protocols.
Managed clinical operations, ensuring compliance with established guidelines and standards.
Executed comprehensive audits of medical records and charge capture processes.
Evaluated length of stay challenges, applying analysis to improve efficiency.
Streamlined utilization review procedures for better resource allocation in patient care.
Delivered prompt inpatient care focused on achieving superior patient outcomes.
Demonstrated initiative and independence in overseeing essential case management functions. - 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.
Sr. Case Manager – Utilization Review
Humana Health Care System
01.1997 - 01.1998
- Directed quality assurance and risk management to strengthen patient safety protocols.
- Managed clinical operations, ensuring compliance with established guidelines and standards.
- Executed comprehensive audits of medical records and charge capture processes.
- Evaluated length of stay challenges, applying analysis to enhance operational efficiency.
- Streamlined utilization review procedures, optimizing resource allocation in patient care.
- Delivered timely inpatient care, prioritizing superior patient outcomes.
- Oversaw essential case management functions with initiative and independence.
- Collaborated with healthcare professionals for optimal patient outcomes.
Utilization Review – Team Leader
United Health Care
01.1995 - 01.1996
- Directed quality assurance and risk management to enhance patient safety protocols.
- Managed clinical operations to ensure compliance with established guidelines and standards.
- Executed comprehensive audits of medical records and charge capture processes.
- Evaluated length of stay challenges, applying analysis to boost efficiency.
- Streamlined utilization review procedures for improved resource allocation in patient care.
- Delivered timely inpatient care focused on achieving superior patient outcomes.
- Oversaw essential case management functions with initiative and independence.
- Collaborated with healthcare professionals to ensure optimal patient outcomes.
Sr. Nurse Coordinator – Utilization Review
Aetna Healthcare
01.1993 - 01.1995
- Telephonic utilization review of 200 nationwide contracts for Indemnity and PPO networks including US territories.
- Pre-certification for admissions, surgical procedures, concurrent review and case management.
- Discharge planning and retro reviews.
- Participating in healthcare providers and Quality Assurance.
- Worked independently, supervised staff ensuring HR Policies and procedures were adhered to and recruiting for the department.
- Accounting duties: Reporting and budgeting tasks.
Clinical Evaluator – Utilization Review Management
Ethic Care Management
01.1991 - 01.1993
- Telephonic utilization review of 100 nationwide contracts for PPO networks.
- Pre-certification and concurrent review of medical, pediatric, neonatal and psychiatric.
- Integrated discharge planning and home healthcare services.
- Worked independently, supervised staff ensuring HR Policies and procedures were adhered to and recruiting for department.
- Accounting duties: reporting and budgeting tasks.
- Managed Quality Assurance and Risk Management programs.
Home Care Coordinator – RN
Memorial Hospital Systems
01.1984 - 01.1991
- Home visits for wound care, IV Therapy, patient education, diabetic teaching and prenatal instructions.
- Supervisory visits evaluating employee performance levels.
- Managing contractual agreements.
- Reviewing concurrent / retrospective review of referrals for HHC.
- Planning and facilitation care for patients between hospital and home setting based on governmental and utilization review guidelines.
- Proficient in knowledge of Medicare, Medicaid Blue Cross/Blue Shield, HMO, PPO, Commercial Carriers Workman’s compensation and other specific contractual agreements and how to correlate to the healthcare industry.
Assistant Head Nurse
Memorial Health Center – Affiliated with UTMB Family Practice Residence Program
01.1984 - 01.1991
- Triage, assess and evaluate patient’s conditions.
- Managed and assisted with ER and special procedures: vasectomies, casting, laceration repairs and flexible sigmoidoscopies.
- Oversee and Initiate health related referrals, and patient teaching to return patients to optimum level of daily living.
- Clinical evaluation and assessment of patient H&P, cardiovascular testing, Holter monitor, stress tests, Recovery Room and outpatient recovery.
- Oversee workmen’s compensation evaluations and official documentation including drug testing.
- Assisting with Family Practice Clinic Residency Program.
- Management skills included updating new policies and procedures, orienting new nursing personnel and residents, and supervising all in-service programs.
- Managed Quality Assurance and Risk Management programs.
- Participating with insurance companies/utilization review departments.
Education
ADN - Nursing
San Jacinto College
Pasadena, TX, USA05.1985
Skills
- Case management
- Chart auditing
- Utilization review
- Denial and appeals management
- Charge capture
- Nurse auditing
- State fair hearings
- Administrative law judge hearings
- Policy formulation
- Leadership skills
Certification
- Texas Nursing License, 530627, 03/21/86, currently active, www.BON.state.TX.us
- ACM-Accredited Case Manager, 72127, 03/31/18, 03/21/26, National Board for Case Management
- CPUR - Certified Status: expired - I am getting this renewed.
- HIPAA certification
- Research certification
Languages
- English
- French
Citizenship
US Citizen, 11/19/75, 10248013, Yes
Languages
English
Professional
French
Elementary
Accomplishments
Denials & Appeals - Recouped 4M in 1 year on Denied claims overturned.
Implemented PSJP - (Patient Stay Justification Program) resulting in cost savings of 3M
Awarded Case Manager Nurse of the year, Honor Health Hospital
Nominated Case Manager of the year 2 times. Honor Health Hospital
Nurse of the year nominated 10 times -
References
References available upon request.
Timeline
RN-Transitional Care Management
HONOR HEALTH
01.2019 - Current
RN-Case Manager
MEMORIAL HERMANN HOSPITAL SYSTEMS
01.2015 - 01.2019
Sr. Nurse Auditor, Clinical Denials & Appeals, Charge Capture RN
Honor Health
10.2005 - 12.2016
Director of Clinical Services & Pharmacy Protocol Program
Interface EAP
01.2002 - 10.2005
Sr. Case Manager & Utilization Review Nurse / Charge Capture and Nurse Auditor
Staff Search Incorporated
01.2002 - 01.2004
Contracts and Order Administration Representative
Aspen Technology INC.
01.2000 - 01.2001
RN Case Manager-Utilization Review
Spring Branch Medical Center
01.1998 - 01.2000
Sr. Case Manager – Utilization Review
Humana Health Care System
01.1997 - 01.1998
Utilization Review – Team Leader
United Health Care
01.1995 - 01.1996
Sr. Nurse Coordinator – Utilization Review
Aetna Healthcare
01.1993 - 01.1995
Clinical Evaluator – Utilization Review Management
Ethic Care Management
01.1991 - 01.1993
Home Care Coordinator – RN
Memorial Hospital Systems
01.1984 - 01.1991
Assistant Head Nurse
Memorial Health Center – Affiliated with UTMB Family Practice Residence Program
01.1984 - 01.1991
ADN - Nursing
San Jacinto College
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