MARY ELLEN ELMORE, R.N.

3054 Heatherbrook Trace

Canton, Georgia 30114
678/493-2013 and 770/367-0505
me4c7388@westpost.net
35 years of managed and acute healthcare experience in operational and direct pa
tient care roles
Positions Held:
5/2010 to present United Healthcare /Health Career Professionals LLC.
Atlanta, Georgia
Care Coordination - Contractor
* State of Georgia Retirees Medicare Advantage Plan (PFFS)
* Clinical liaison between the member and the community
* Care coordination with other health professionals related to the members chron
ic disease state which include CHF, Diabetes, CAD, and COPD
* Promote member independence while preventing avoidable decline
* Prevent unplanned hospitalizations and avoidable readmissions
* Prevent or delay out-of-home placement to a more restrictive environment
* Promote medication reconciliation, medication management systems
* Provide appropriate access-right care, right time, right provider, right place
* Promote member engagement and satisfaction
* Promote Primary Care Physician (PCP) engagement and satisfaction
6/2009 to 5/2010 Blackstone Resources/ Soliant Healt
h Atlanta, Georgia
Appeals Specialist - Contractor
* Denial resolution for Children's Healthcare of Atlanta
* Medical Chart audits - First and Second Level Appeals (administrative and clin
ical)
* Appeals included all payers - Commercial, Medicaid, Medicare and MCO
* GHP web portal experience - Medicaid (retro -auth)
* Reviewed claims for appropriate coding ICD9, CPT, HCPCS, and revenue codes
* Knowledge of CMS's (version 27) MS-DRGs
* M&R and InterQual guideline experience
10/2005 to 9/2009 Medicare QIO/Georgia Medical Care Founda
tion Atlanta, Georgia
Patient Safety Quality Advisor /Compliance Auditor / Statewide Clinical Coordina
tor
* Improved patient safety across the continuum of care which included hospitals
and nursing homes in order to reduce process variation associated with patient (
contract deliverables)- CMS's 9th SOW
* Lead for the Drug Safety Project - to reduce the use of medications associate
d with DDI and PIMs in the Medicare population that were enrolled in Medicare Ad
vantage Plans and Prescription Drug Programs - CMS's 9th SOW
* MCO Medicaid Compliance Auditor - Medicaid
* Statewide Clinical Coordinator - Preventive Guidelines (mammography, cancer, d
iabetes, immunizations) - CMS's 8th SOW
* Diabetic Medication Management Initiative in the underserved areas of Georgia
in collaboration with the Georgia Pharmacy Association - CMS's 8th SOW (artic
le published)
* Lead for the Georgia Immunization Coalition which included CDCP, DCH, Merck,
Sanofi-Pasteur, Novartis, Physician Alliance, Maxim Health Services, Med Immune,
Institute for Wellness and Education and GlaxoSmithKline (GSK) - CMS's 8th and
9th SOW
* Assisted physician offices with decision making related to the adoption of ele
ctronic medical records associated with CMS's DOQ-IT Project - CMS's 8th SOW by
proving information regarding available software that tracked CMS's requirement
s associated with preventative measures and disease management
* Understanding of CMS terminology and web site
5/2005 to 10/2005 3M Health Services
Atlanta, Georgia
DRG Consultant
* Improved inpatient record documentation by establishing a coordinated, systemi
c process utilizing a concurrent review team
* 3M DRG grouper experience (software)
* Identified strategies to more accurately and completely capture a patient's se
verity of illness and risk of mortality in clinical documentation, which typical
ly resulted in a 4:1 return on investment and a 2-4% increase in case mix index
* Increased communication and teamwork between physicians, case managers, utiliz
ation review, quality management, and health information management staff.
* Taught MDC's to large 400 bed hospital
1975-1997/2001-2005 Acute Care
Atlanta, Savannah, and Athens Georgia
Case Management Director/ Quality Director/PI Coordinator
* Case finding
* Comprehensive assessment of client situation
* Evaluation and coordination of the plan of care
* Matching client resources to client need
* Monitoring delivery of services
* Critical thinking, appropriate prioritization, and time management
* Measurement and evaluation of financial, clinical, functional, and satisfactio
n outcomes
* Accountability for financial, clinical, functional, and satisfaction outcomes
* Evaluation and response to the learning needs of clients, clinicians and commu
nity
* Care coordination and LOS
* Care planning based on diagnosis - care paths
* Clinical protocol/guidelines experience
* Coordinated all aspects of QM (PI) activities which has included clinical and
non-clinical services
* Experience with application of Balanced Scorecards (Dashboard of Indicators)*
* Statistical Analysis of data utilizing QI tools
* Performance Measurement and Management expertise
* Through understanding of regulatory standards that includes coordinating and p
resenting information to JCAHO
* Process evaluation and revisions (streamlining existing workflows)
* Policy and procedure writing experience (workflows)
1997 to 2001 Managed Care
Atlanta, Georgia
Quality Director /Senior Quality Analyst/UR Nurse
* Review of prospective, concurrent and retrospective clinical cases utilizing M
& R guidelines and InterQual criteria
* Through understanding of regulatory standards that includes coordinating and p
resenting information to URAC/AAHC and NCQA on-site surveyors*
* HEDIS indicator collecting and reporting experience
* PIP writing experience
* Data collection and analysis
Education
AASU 1972- 1975 returned times 2
Nursing - ADN / One and half years towards BS in nursing (enough credits for gen
eric Bachelors degree)