SUSAN LEE

Supervisor-Tara Marlow( HEDIS measure 5), Bridget Jenkins( HEDIS measure 7)-(629.258.2528)
Pay per chart/ HEDIS seasonal contract

( January-May)Review health plans medical records and abstract relevant clinical HEDIS data.

• Perform quality reviews of abstracted medical records.
• Identify appropriate information from medical records according to NCQA HEDIS and Change Healthcare quidelines.
• Data entry abstraction results in software system.

Supervisor -Stacy Qualls ( 714.421.8356)
Full time/ 40 hours per week ( 5 month project contract) $75.00 per hour

• Develop agency survey tools to align with State and Federal Laws, CMS regulations relating to medical facilities( Home care services, Private duty nursing services, Personal care services, Orthotics and Prosthetics, Durable medical equipment, Rehabilitation therapy services).
• Develop a training program for agency nurse surveyors for continued and onboarding training.
• Conduct inspections, investigations, surveys and evaluations of health care facilities for credentialing requirements, in compliance with Texas Children's Health Plan, NCQA and Hedis measures, State and Federal laws and CMS regulations relating to medical care.
• Collaborate and provide recommendations regarding site survey /audit results and develop corrective action plans to facilitate correction of deficiencies identified.
• Review all relevant health care facilities policies and procedures as it pertains to the site survey and provide recommendations for quality improvement.
• Perform site revisits to identify correction of any deficiencies and document completion of site survey.
• Gathered, organized and modeled data for survey reports and presentations.

Supervisor- Jennifer Hazinski (866.902.4000)
Full time
Salary $80,000/year

• Receive patient referrals in conjunction with intake team supporting basic data entry of patient demographic, insurance, and chart creation.
• Perform care coordination and follow up with providers, patients, family members, referred facilities and other referral sources.
• Assign diagnosis codes to admission and validate diagnosis codes.
• Identify admission barriers and provide information and assistance to address issues.
• Obtain verbal orders from physicians to initiate care/services.
• Coordinate with referral sources regarding home health care admission criteria per CMS and ACHC guidelines.
• Track and monitor cancels/non-admissions.
• Ensures compliance with all state, federal and referral intake regulatory requirements for home health care.
• Coordinate with billing regarding insurance eligibility
• Communicate with referral sources to obtain required referral documentation.
• Design and pilot a quality initiative program regarding start of care to improve quality measures, increase patient safety and compliance with conditions of participation rules and regulations.

Supervisor-Kimberly Cope( 800.852.7795)
Part-Time contract ( 20-30 hours) $38 per hour

• Review internal appeal requests and conduct investigations involving provision of service issues.
• Contact customers to gather information and communicate disposition of case.
• Utilize established criteria, MDHHS contract, CPT/HCPCS coding, other resources, and clinical evidence to develop sound and well-supported appeal decisions.
• Triage case inquires, appeals, and prepares case files for appeal hearings.
• Generates written correspondence to review boards, legal/representatives, providers, and regulatory agencies.
• Collaborate with the Chief Compliance and Quality officer to determine appropriate course of action/ responses when necessary.
• Perform and submit internal audits {CQAR} into the State of Michigan portal.
• Develop correction plan as to pertains to the CQAR internal audit results and disseminate to applicable clinical/supportive staff.
• Identify quality trends to the Quality Manger and discuss system deficiencies, process inefficiencies and training needs.
• Reported on audit results to inform stakeholders of areas in need of improvement.
• Serve as the medical consult to the Compliance and Quality department on complex medical case reviews.

Supervisors- Tarek Albitar and Laura Manza
( 855.996.2264)

Full time Salary $78,000/ year

• Write requests for proposals and operating contracts related to nursing services.
• Conduct audits for utilization management and proper CPS/ HCPCS coding of healthcare performance and practices.
• Identify and recommend process improvement initiatives based on audits trends and root cause analysis.
• Initiate, facilitate, and promote activities to foster compliance awareness.
• Develop and implement policies and procedures related to healthcare services, patient safety, pharmacy, and laboratory services for both contracted and direct service providers of the managed care organization.
• Educate MCCMH direct and contracted agencies on utilization, implementation and compliance of organizational policies and procedures.
• Provide consultation to the MCCMH Hearing Officer on Medicaid adverse benefit determinations as to pertain to pharmacy, medical services and supports.
• Attend Medicaid Fair Hearings involving upheld Medicaid Adverse benefit determinations as it pertains to medical, CLS, Respite and pharmacy services.
• Respond to corporate compliance inquires, requests, complaints and grievances related health care and investigate documents thoroughly.
• In-service, educate, and train physicians and staff on topics such proper coding, risk management, quality of care, fraud and abuse laws and standards of conduct.
• Collect, measure, aggregate, and present data required for monitoring and improving nursing/medical quality of care and reduce risk practices.
• Review Private Duty Nursing requests, perform consumer eligibility in-home assessments, and provide service recommendations for authorization of services.
• Audit clinical documentation to ensure that it aligns with regulations outlined the Medicaid Provider Manual, CPT/HCPCS coding , Public Health Code and other statues of law
• Organize and lead quarterly meetings with MCCMH contracted Nursing Skilled home care organizations to review updated PIHP policies and procedures, facilitate resolution of identified issues, and enhance provider communication.

Nurse Quality Coordinator , June 2013 - June 2015

• Develop policies, procedures, and projects for quality assurance and improvement.
• Investigated performance to maintain employee adherence to quality and safety policies.
• Recommend procedures for increased productivity.
• Designed quality improvement studies.
• Trained and led staff on proper QA standards.
• Collaborated with other team members to perform internal QA audits.
• Reported on internal and external outcomes of quality activities to project stakeholders.
• Developed and Chaired the Agencies Nursing practice council and Nursing leadership Committee.
• Responded to compliance inquires, requests, complaints and grievances related to nursing.
• Conduct periodic program audits for performance management and CPT/HCPCS proper coding of health care practices.
• Educate direct and contract agencies on utilization management, organizational polices and procedures, health care law, and public recognized practice standards.

Supervisor-Pam Lively ( 313.473.1000)
Full Time Salary
$80,000/ year

• Administered oral, intramuscular and IV medications to patients and monitored responses.
• Treated patients suffering from chronic and acute medical concerns.
• Delivered high-quality nursing care to patients on -35 bed medical-surgical unit.
• Oversaw patient admission and discharge processes to coordinate related paperwork.
• Oversaw patient admission and discharge processes to coordinate related paperwork
• Trained and mentored new RNs on best practices, hospital policies and standards of care
• Monitored and educated nursing students and externs on proper care procedures and prioritization strategies
• Developed and adapted individualized treatment plans according to patient recovery goals.
• Maintained personal and team compliance with medication administration standards and patient care best practices.
• Assisted patients with healing and recovery after surgery by closely monitoring and caring for wounds, answering questions and educating about continued care strategies.
• Performed blood and blood product transfusions and intravenous infusions to address patient symptoms or underlying causes.
• Prioritized nursing tasks and assignments and accurately reported patient status.
• Acted as patient advocate and implemented total patient care through team nursing process.