Cathy L. Kauffman BSN, RN, CCM, LNC

108 Pacolet Street, Summerville, SC 29485Email; psunsg1975@gmail.com

Cell: 814-935-2884

Summary of Professional Skills

Professional and progressive management preceded by diverse clinical experience including med-surg, emergency, long term care, behavioral health, and addictions care; case and disease management in managed care/insurance, dual eligible population health, and worker’s compensation. Start-up of Medicare-Medical Dual Eligible of integrated Medical Management Demonstration in SC and independent consulting business.

Extensive experience with multiple successful Accreditation, State and CMS reviews in utilization and case management. Successful accreditation and quality improvement experience specific to HEDIS, NCQA, URAC, and JCAHO. Independent Medical legal consultation, HIPAA Readiness Consultation, Case Management.

Certifications have included Medical-Surgical, Legal Nurse Consultant, Managed Care, and Case Management.

Other professional character attributes: Self-Starter Succession Planner Persistent Change Agent Objective Situational Leader

Best Practice Vision Proactive Succession Planner Supportive and Successful

Mentor

Summary of Experience

Progressive Management – Director Amerihealth Caritas First Choice VIP Medicare-Medicaid Integrated Medical Management SC Demonstration start up, BCNEPA Sr. Director Clinical Operations (leadership of a staff of 100 working in medical management and quality management); Nursing Director Drug/Alcohol and Behavioral Healthcare Facility; Highmark Director Utilization and Case Management, and Director of Quality Improvement; Regional Manager Care/Case Management Capital BC; Crawford Regional Manager Worker’s Compensation. Other management experience includes: Unit Supervisor Long Term Care; and Unit Nursing Coordinator Medical/Surgical VA Hospital; Compliance Director Landacorp (National Managed Care Software).

Healthcare Quality and Compliance – JCAHO, URAC and NCQA accreditation, HEDIS, DOH, HCFA/CMS. Director of Regulatory Compliance with for national managed care Software Company; JCAHO and DOH compliance for Behavioral Health; Consultant - Healthcare and HIPAA Compliance. Recent introductory skill development with STARS.

Educator – Presenter at national level on diverse healthcare subjects pertinent to utilization nurses, case managers, other healthcare professionals, and attorneys relating to medical/surgical, long term care, case management, risk management, legal issues, and quality improvement issues. Prior

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instructor for Accredited LPN Program. Published. History of proven successful staff development. Recent (February 2016) presentation to Clinical Research audience on the topic of “Role of Case Management in Clinical Research.”

Owner/Consultant - Integrist Healthcare Consulting, LLC privately owned consultation providing Legal Nurse Consulting – Medical-Surgical and Long Term Care Legal Consultation; Case Management Services; Healthcare Compliance Consultation, HIPAA Privacy Consultation, Training and Education; Case Management Program Development; National Level Healthcare Educator/Presenter.

Sales and Marketing – Quadrupled the client base for regional PA Worker’s Compensation site to insurers/self payers and employers; sales of independent medical/quality/legal services

Diverse Clinical Experience – Includes but not limited to Emergency, ICU, medical/surgical, home health, hospice, long term care, behavioral health, and drug and alcohol addictions care.

Medical Management and Case Management – Diverse care coordination experience including: Employer based and Independent Case Management Services, Disease/Condition Care Management; Utilization Management, Disease Management; Worker’s Compensation; Managed Care Case Management Services for Commercial, Medicare and Medicaid products.

Professional Employment Experience

Evolent Health – (Through the Jacobson Group)DSNP Case Management 10/26/2016 to PresentCare Manager/Advisor –Remote

Transition of Care - Care Manager o MSSP – Medicare Shared Savings Programo Care coordination from initial assessment, through short term care

planning through at least 4 weeks post discharge o Education of member/care givers, reassessments throughout changes

to level of care, implementation of action items in accordance with established and prioritized goals, and evaluation of outcomes

Complex Care - Care Managero In accordance with the standards for case management during long

term complex care management of members with multiple chronic conditions

AmeriHealth Caritas – First Choice VIP Care Plus Medicare-Medicaid Demonstration – South Carolina 03/16/2015 – 09/14/2016 Director of Integrated Medical Management Reason for Leaving: Business Reorganization and Leadership Realignment

Management of all aspects of the case and chronic disease management program

Implementation of person centric model of care consistent with Three Way Contract Standards and Elements

Development of effective care coordination and transition of care processes Staff development, evaluation, and education

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Strategic process enhancement to reduce readmissions, reduce avoidable admissions, and optimize implementation of home and community based services to enable members to remain safely in their homes

Adherence to mandated assessment, care plan, reassessment and multidisciplinary team meeting regulations

Integration of medical and behavioral health services through proactive individualized care planning

Evaluated in collaboration with multidisciplinary team the identification of Members eligible for long term support services

Written Program Protocol, Program review and annual revision, Policy development and work flow development

Developed strategic proposals related to transition of care processes Audit validation of care coordination compliance with the Three-Way Contract

with SCDHHS and CMS Incorporation of HEDIS measures in all aspects of care coordination as

appropriate Contributor of authentic data to SC and CMS reports

BCNEPA – Blue Cross North East Pennsylvania 11/11/2011 – 03/14/2015Sr. Director Clinical Operations

Quality and Utilization Management Program development, implementation and improvement

Coordinated NCQA strategy for achievement of HMO NCQA reaccreditation; First PPO NCQA accreditation – Successful Accreditation

Oversight of QM and NCQA accreditation to achieve the plan’s first score of 100

Evaluated and implemented departmental improvements such as creation and/or reassignment of the right people to the right job

Developed a Transition of Care program to close gaps in care between acute care discharge and home; Webinar presentations to provider groups and Federal Accounts (FEP)

Implemented the first Leadership and Bench Training in collaboration with HR o Included over 20 sessions over 1 ½ years; 11-22-13 graduation of first

class to create proactive and effective succession plano Developed Bench training program to strengthen succession plan

Coordinated and oversaw aggressive HEDIS improvement plan Collaborated with Provider Contracting Department to for development and

measurement of quality and utilization metrics as related to facility incentives Implemented proposal submitted and approved by CEO for inclusion of clinical

and quality oversight of PCMH Exceeded projected annual cost savings targets my first year; achieved

greater savings in 2013; and continued to exceed savings in 2014. Created value add positions within UM and Quality departments from existing

positions including a Delegation Manager and Project Manager Reorganized and established aggressive departmental goals to optimize

quality, accreditation and care cost savings outcomes Developed a proactive leadership succession plan and training Rewrote and/or developed job descriptions across entire reporting

departments Developed and obtained approval for departmental career ladder to create

growth opportunities for stellar staff Collaborated with multiple organizational teams for implementation of

Affordable Care Act implementation Identified, tracked and trended utilization trends monthly identifying

opportunities and/or needs for expeditious corrective action

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Implemented new nationally established criteria sets within UM to optimize healthcare specific reviews and justifiable savings

Promoted a departmental vision of best practice achievement through process improvement, stretch goals, staff development, and achievement of appropriate certifications.

Oversaw development and implementation of aggressive UM and QM strategic work-plans ensuring timely milestone/outcome achievement and optimal measurable outcomes of multiple initiatives

Celebrated success!

Centene Corporation – Absolute Total Care 03/22/2010 – 11/01/2011Managed Care Organization/Medicaid 80k – 100k Members

Manager of Case/Utilization Management Revision and reorganization of case management program Care coordination oversight and management of Case Management Team of

RN Case Managers, Social Services, Program Coordinators, and Member Connections Representatives

Program coordination of Connections Plus Program – Member outreach services

Quality and process improvement project coordinator NCQA Accreditation 2010 HEDIS incorporation into case management SCDHHS state audit 2010 and case management review Program coordinator for special projects including but not limited to

Hemophilia, Sickle Cell, High Risk OB, and other high cost and complex disease processes

Annual policy and procedure review and revision

McKesson 05/05/2008 – 03/17/2010

Remote: Community Based Field Case Manager/Medicaid Disease management services and care coordination for Pennsylvania

Medicaid members Provider education and assistance with care coordination for patient members Analysis of care options, implementation of individualized education strategies

and fluid measurement of member outcomes

Cove Forge Behavioral Health – White Deer Run – Williamsburg, PA 11/01/2005 – 05-02-2008Director of Nursing – 170 bed facility

Nursing Director Adult Rehab/Detox and Residential Treatment Facility Community Liaison Compliance - PA and Federal Behavioral Health Regulations; JCAHO

Accreditation and DOH surveys Departmental Quality Improvement and Protocol Development Coordination - Staff Development and Client Education Risk Management/Safety Committee/Project Management

Capital Blue Cross – Allentown Regional Office of Harrisburg, PARegional Manager of Care and Case Management Reason for leaving: Terminally ill family member

02/2005 – 10/2005

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Care and Case Management of NE Region for commercial and Medicare members

Case management system program development o Software Vendor - TriZetto – ClinicalCare Advance

URAC – DOH – CMS – NCQA Accreditation Discharge Outreach Program Utilization and cost management Budget development and management Staff development and training

Greater Altoona Career and Technology Center – Altoona, PA 08/2004 – 02/2005

Program Director/Instructor – New Choices/New Options Instructor – Medical Assistant Curriculum/HIPAA Privacy

Integrist Healthcare Consulting, LLC. – Pittsburgh/Duncansville, PA Legal Nurse, Case Management, and Compliance Consulting ServiceIndependent Consultant

2000-2005

Legal Nurse Consultant (Occasional services continue) Review and Analysis of Medical Records – Comprehensive Reporting Medical Malpractice, Managed Care, Personal Injury, and Criminal

Litigation Assistance Nursing Home negligence specialization; DUI cases; General Adult

MalpracticeCase Management and Elder Care Management Services Consultant

Case Management Services – Health and Workers Compensation Care Coordination

Care Coordination Services – Elder Care Coordination – Long Term Care Coordination

Education HIPAA Privacy, Case Management, Medical/Legal

Practice Management Consultant Acting Director

Compliance Consultant HIPAA Privacy Services, URAC Case Management Services Physician NCQA Credentialing and HEDIS Services

Landacorp, Inc. - Atlanta, GA 2000-2001Medical Management Software Company – (Laid off 1-4-2001) Director of Regulatory Compliance

Research, analyze and incorporate all pertinent regulatory and accreditation standards into internal policies, procedures and training manuals and client education programs

Compliance expertise included URAC, HCFA, JCAHO, DOH, and HIPAA regulations

Highmark Blue Cross and Blue Shield - Pittsburgh, PA 1995 - 2000Managed Care Organization

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Director of Quality/Compliance Accreditation/compliance management pertinent to utilization review and

case management processes for HCFA/QISMC, NCQA, URAC, and DOH with 5 years of accreditation success.

Organizational Director of Care and Case Management – Pittsburgh, PaPromotion

Developed and managed care/case management division, including: Medicare +Choice, Behavioral Health, Commercial, National, and Quality Improvement units, including 300 employees

Case Management Program development - Landacorp Implemented Provider Education and Disease Management Programs Coordinated Staff Education/Case Management and UM Certification

Programs Achieved successful HCFA, NCQA, DOH and URAC accreditations Appointment to URAC Commission for the development of National Case

Management StandardsRegional Director of Care and Case Management – Johnstown, Pa

As above on a regional level

Crawford HealthCare and Rehabilitation Management - Altoona, PA 1990 -1995 Worker’s compensation, healthcare, and disability case management organization Consultant-in-Charge/Regional Manager

Provided oversight and management of case and vocational consultants Case Management – worker’s compensation/health Sales and marketing to new and existing accounts Prepared cases for litigation and assisted in deposition preparation

Valley View Nursing Home – Altoona, PA 1990Long-term care facilityNursing and Facility Continuing Education InstructorEducation and Quality Improvement Coordinator Developed staff education program and facility policies, Assessed and measured

quality of care in accordance with DOH requirements Coordinated and instructed nursing aid certification and training

Veterans Administration Medical Center – Altoona, PA 1983 – 1989Federal Veterans Administration Hospital Utilization Review and Quality Improvement Coordinator 1987 – 1989 Utilization review, Quality Improvement and Staff EducationIn-service Coordinator 1985 - 1987 Staff education, annual review compliance, program development, career

advancement committee Surgical Unit Staff – Promoted to Head Nurse within 3 months 1983 – 1985

Additional Professional Experience Clinical - Emergency, Medical,

Surgical, Drug and Alcohol, Psychiatric and LTC from 1975 through 2008

Nursing Education/Instructor Hospice/Home Health Care Health Insurance/Sales Sales/Marketing

Education

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BSN – Nursing - Pennsylvania State University, State College, PA – 1975 Masters in HealthCare Administration – Incomplete - California College for Health

Sciences, 222 W. 24th St., National City, CA 91950 – Completed 15 Credits – 1999

Professional Certifications

Certified Case Manager: 1993 – Present Certified Legal Nurse Consultant: 2001 – 2006 Certified Managed Care Nurse: 1996 - 2006

Publications

Appointed to editorial board of Case in Point – August 2013 Case in Point – “Fortifying Powerlessness – Managing Unmanageable

Lives,” December 2007 ADVANCE – “Case Management and HIPAA” – June 2001 ADVANCE - “The Ying and Yang of Case Management – Balancing Cost and

Quality” – September 1999 ADVANCE – “Case Management Opportunities in Managed Care” – January 2002 ADVANCE – “Case Management Outcomes” – March 2002 Journal of Care Management – “HIPAA – A New Protected Species” – July/August

2001 Bimonthly Newsletter - Integrist Healthcare Consulting, LLC West Allegheny Magazine – Regional Pittsburgh Magazine – “How to Select a

Nursing Home” – July/August 2001 HIPAA 101 – “Cool Tools” Web-Based Program – PRIME Author/Continuing Care – “Case Managers: Planning for Life through Life Care

Planning” – December 2002 Inside Case Management – “Just Do It … HIPAA Privacy” – January 2003 Discharge Planning – “Marketing with HIPAA” – Fall-Winter 2004 Editor – Lippincott and Williams - 2003 to present Editor – PRIME - Continuing Education Courses – 2002 to present

Presentations

Speaker – Clinical Billing and Research – “Role of Case Management and Care Coordination in Clinical Research.” – February 2016

Speaker – Wyeth Pharmaceutical Conference – Case Management and Patients with Depression – September 2008

Speaker - CMSA June 2005 - The Role of TNF Modifying Agents in the treatment of Rheumatoid Arthritis

Speaker: MOSBY Case Management Conference – November 2003 – Presentations: Case Management and HIPAA and Case Management Malpractice and Litigation

Speaker: General Topics include: Case Management Issues, HIPAA Privacy, Clinical, and Medical-Legal Case Issues

Speaker: NBI (National Business Institute) Nursing Law Update Seminar - “Universal Healthcare Issues” and “Current Legal Issues in Nursing”

Speaker: NBI (National Business Institute) Medical Record Review and Analysis for Attorneys

Speaker: DUPONT National Case Management Presenter (Deep Vein Thrombosis) - 2000 thru 2001

Speaker: NBI – (National Business Institute) - Nursing Home Negligence – November 8, 2002

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Speaker: NBI (National Business Institute) Medical Record Review for Paralegals Speaker: Lorhman Institute - HIPAA Privacy for Healthcare Professionals Speaker: CMSA Annual Seminar and Nationally – “Legal Issues and Case

Management” Speaker: PRIME, INC. - Low Back Pain Case Management, Rheumatoid Arthritis

and DVT National Presenter PRIME, INC. – Program Development Editor and Speaker PSNA – Speakers Bureau 2001 ASPE – American Society of Professional Education – HIPAA Privacy Compliance Educator: Community College of Allegheny County – Part Time Case Management

Certification Instructor Educator: HIPAA Privacy Workshops – Altoona Career and Technology Center Speaker: Centacor – “Managing Rheumatoid Arthritis” Auditor: Perigee Healthcare Consulting – NCQA Physician Office

Assessments/Health America Client Auditor: Outcomes, Inc. – NCQA Physician Office Assessments/Health America

Client Case Manager Subcontractor - Nation’s Care Link – Long Term Care Nurse

Assessment – Subcontracting Services Case Manager Subcontractor - Bunchcare and Associates, Inc. – Case

Management Services

Advisory Committees

GENENTEC Advisory Committee – National Case Management Committee 1998 - 1999

SANOFI Advisory Committee – National Case Management Committee 1999 STADTLANDERS Advisory Committee – National Case Management Committee

1999 CMSA – Pittsburgh Chapter – Member and Education Committee – 2001 URAC Case Management National Advisory Committee - 1998 URAC (National) Education Advisory Committee- 2000 CMSA (National) Nomination Committee - 2000 CMSA Special Interest Group (Acute Care) Moderator – 200l CMSA Acute Care (SIG) Leader – 2001 – 2002 Blair County Chamber of Commerce - Health and Safety Committee – 2002-03

Professional Organizations

Case Management Society of America (CMSA) Association of Manager Care Nurses (AMCN)

References available upon request

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