Vivian C. Binenstock

• Direct and provide leadership for designing, developing, and implementing integrated medical management program to meet the demographic and epidemiological needs of the populations serviced.

• Partner with other health plan/corporate leaders to develop and deliver innovative care management services, root cause analyses and solutions to achieve quality outcomes.

• Direct Healthcare Management Program including disease management, case management, and utilization management.

• Partner with Provider Solutions, Quality Management, Health Promotions, and Community Relations to develop and implement effective provider communications, quality assurance, and member outreach programs.

• Provide expert consultation to local plan staff on benefits interpretation and utilization and quality management matters.

• Ensure support for compliance with National Committee for Quality Assurance (NCOA) and assures compliance with state/and or federal program requirements.

• Hire, train, coach, counsel, and evaluate performance of direct reports.

• Promoted from Care Manager to Manager with 25 direct reports
• Successfully completed Anthem's Director Development Program in 2018 and Frontline Leadership Fundamentals in 2015
• Created and implemented standardized care management documentation to meet state contract requirements that led to improved state audit scores
• Implemented new workflows for care managers, such as weekly review of inpatient admissions of members being care managed
• Developed PDN process and new assessment tool with interdisciplinary team that resulted in state approval
• Work closely with Director of Healthcare Management on various NJ Plan initiatives including but not limited to CoC, PHM, UM, CM, state audits. Participant in Senior Leadership meetings and provide coverage for Director
• Active participant in daily inpatient rounds, outlier rounds, and implemented BH PH integrated CM rounds
• Lead for responding to all UM and CM state complaints
• Worked closely with Director of Healthcare Management on implementation of community-based care management (CBCM)
• Collaborate with NJ state contacts at DMAHS (Division of Medical Assistance and Health Services) and OQA (Office of Quality Assurance) on UM and CM-related business
• Onboarded new employees with training and new hire documentation
• Cross-trained existing employees to maximize team agility and performance
• Successfully shifted responsibility of NJ new enrollee assessment dialer process from centralized team in Virginia Beach to NJ Plan to include CM staff, Avaya (now Genesys) technology and required state reporting

• Care manager for medically complex Medicaid members
• Telephonically assessed physical and psychological factors while coordinating healthcare with providers and providing community resources
• Interfaced with Medical Director on development of care management treatment plans as needed

• Promoted from Care Manager to Supervisor
• Worked closely with Assistant Medical Director and Manager of Quality Department in creating workflows for Live Well Programs
• Performed short-term case management for patients discharged from Overlook Hospital, Summit, NJ, who were at high-risk for re-admission
• Interviewed, hired and trained new employees for care management positions
• Reviewed patient medical records to create appropriate case management plans based upon clinical pathways for cardiology patients
• Coordinated care for patients of multiple providers to achieve Live Well Program goals

• Responsible for regional implementation of corporate and regional medical management strategies and goals
• Developed and implemented corporate CM/UM policies and procedures in accordance with state, federal, and accreditation status for 13 states
• Managed day to day performance of all UM and CM staff
• Evaluated departmental reports against benchmarks with Medical Director
• Developed and implemented departmental UM and CM policies and procedures in accordance with state, federal, and accreditation standards

• Promoted from UM nurse to Senior UM Nurse
• Certified in Milliman Care Guidelines. Used InterQual for certain services
• Performed admission reviews for medical necessity using above criteria
• Evaluated medical guidelines and benefit coverage to determine appropriateness of services
• Assisted Director of UM with management of UM staff
• Performed telephonic prospective, concurrent, and retrospective reviews for HMO, PPO, and POS members
• Awarded Team Excellence Award - nominated by co-workers
• Served as subject matter resource, providing information related to utilization management, including discharge planning