1. Cathy L. Kauffman
BSN, RN, CCM, LNC
108 Pacolet Street, Summerville, SC 29485
Email; 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,
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2. and attorneys relating to medical/surgical, long term care, case management,
risk management, legal issues, and quality improvement issues. Prior
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 Present
Care Manager/Advisor –Remote
• Transition of Care - Care Manager
o MSSP – Medicare Shared Savings Program
o 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 Manager
o 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
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3. • 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
• 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 – 03/14/2015
Sr. 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 plan
o 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
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4. • 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
• 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 – 11/01/2011
Managed 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 – 05-02-2008
Director of Nursing – 170 bed facility
♦ Nursing Director Adult Rehab/Detox and Residential Treatment Facility
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5. ♦ 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, PA
Regional Manager of Care and Case Management
Reason for leaving: Terminally ill family member
02/2005 –
10/2005
♦ 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 Service
Independent 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
Malpractice
Case 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
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6. Landacorp, Inc. - Atlanta, GA 2000-2001
Medical 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 - 2000
Managed Care Organization
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, Pa
Promotion
♦ 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 Standards
Regional 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 1990
Long-term care facility
Nursing and Facility Continuing Education Instructor
Education 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 – 1989
Federal Veterans Administration Hospital
Utilization Review and Quality Improvement Coordinator 1987 – 1989
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7. ♦ Utilization review, Quality Improvement and Staff Education
In-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
♦ 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
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8. ♦ 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
♦ 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
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9. ♦ 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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10. ♦ 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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