Amie Jacobs, RN 768 Seawind Way

Port Hueneme, CA 93041 (818) 300-1222 Cell/Home

Work Experience

January 2014-Present

Health Net Of California

Woodland Hills, California Care Management Specialist II, State Health Plans. CalViva

• Works with Physician and Hospitals to enforce treatment plans and orders • Develops Care management policies and procedures, and facilitates and recommends

process improvements

• Coordinates basic benefit. Identifies and submits modifications, requests for exceptions or special programs

• Advises patient of length of stay and helps anticipate and arrange for services at discharge utilizing Truven/Interqual criteria and clinical nursing judgement

February 2011-Sep 2013

LA Care Health Plan

Los Angeles UM Specialist/Care Management Specialist

• Responsible for prior authorizations, concurrent and retro clinical reviews for Medi-Cal members. Responsible for authorizations for SPD and DHS members.

• Transition to the SNP/Medicare product. Responsible for transition of care notifications, concurrent review and discharge planning.

October 2007- May 2009 American Red Cross

Pomona, California Blood Bank supervisor, Mobile and fixed sites.

• Supervise one or more collection operation functions and staff supporting mobile and

fixed site allogeneic and specialized blood product collections • Ensured the site at all times was in compliance with standard operating procedures,

Safety Quality Identity Potency Purity (SQUIPP), regulations outlined in the Code of Federal Regulations (CFR), Occupational Safety and Health Administration (OSHA) and other applicable Federal, state and local regulations.

July 2007- July 2011

Managed Care Resources

Los Angeles, California Telephonic Case Management, Utilization Review, Prior authorization - contract assignment

positions UCLA, Queen of the Valley Hospital

• Knowledge of InterQual, Medicare, Medical, PPO, HMO guidelines and criteria • Daily Patient Review with Multiple Vendors LTAC, Home Health, SNF and TCU

• Interfaces with Medical directors and Physician advisors developing care management plans

• Responsibilities include patient population ICU, CCU, Telemetry ,NICU,OB and Med/surg

• Retrospective reviews for Medicare, Med-iCal members who received services for Home Health, Skilled Nursing Facilities and Long Term Care.

Jan 2005-Jan 2006 Health Net of California

Woodland Hills, California

Clinical Nurse Specialist II, Grievance & Appeals • Retrospective review of potential Quality of Care/Service issues identified by

members, medical groups and internal staff • Assigned level of severity after review and clinical summary write-up. • Handled member appeals for services denied by medical groups.

• Utilized Medical Director or Specialty Match reviews as necessary. • Worked within state mandated timeframes for expedited appeal vs. routine appeals.

Apr. 1993-Jan 2005 Managed Care Resources

Los Angeles, California Utilization Management Nurse, Temporary Assignments Agency • Knowledge of InterQual, Medicare, Medical, PPO, HMO guidelines and criteria

• Daily Patient Review with Multiple Vendors LTAC, Home Health, SNF and TCU • Interfaces with Medical directors and Physician advisors developing care management plans

• Responsibilities include patient population ICU, CCU, Telemetry ,NICU,OB and Med/surg • Concurrent review UCLA Hematology/Oncology/BMT • Prior Authorizations for FHP Health Plan

Oct. 2000-Jan. 2002 Sherman Oaks Hospital Sherman Oaks, California

Director, Case Management • Develop, manage and direct Utilization Management Program.

• Provide overall direction, design, development, implementation, and monitoring of utilization programs to meet the hospital’s utilization goals while maintaining customer satisfaction.

• Act as a resource to medical and administrative staff. • Analyze and report significant utilization trends, patterns and impact to appropriate

departmental and medical staff committees. • Develop, monitor and control department’s budget.

• Assure compliance with Federal, State, JCAHO, and other regulatory agencies and internal standards and requirements.

• Hire, coach, train, and discipline staff to ensure smooth operation in utilization management.

Nov. 1998-Oct. 2000

Aetna US HealthCare Woodland Hills, California

Manager, Patient Management • Administrative and operational responsibility for HMO product of Prudential

HealthCare statewide and integration of AUSHC Southern California and San Diego

business to the Woodland Hills location, accounting for over one million HMO lives. Supervised staff of 34 including clinical and non-clinical FTE’s involved in

pre-certification, concurrent review, discharge planning, case management, organ transplants, and retro claim review.

• Assisted Site Manager with policy and procedure development and implementation,

utilization analysis and reporting, audits, compliance with regulatory standards and budgeting.

Nov 1998-Oct 2000

Prudential Insurance Company was acquired by Aetna US HealthCare

Network Management Nurse/Delegation Oversight • Monitored and evaluated PMG’s/IPA’s Utilization Management and Quality

Improvement Programs to ensure they met Prudential HealthCare’s contractual and regulatory requirements.

• Performed on-site PMG/IPA Utilization Management and Quality Improvement

Programs’ evaluation using a standardized audit tool. Implemented corrective action plan based on audit findings.

• Co-chaired JOC’s, wrote and submitted minutes to Network Oversight Committee. • Participated in NCQA accreditation process.

Education

June 1997- August 1999 Regents College Awarded Associate in Science, Nursing, with Honors (R.N.)

Albany, NY

September 1979 L.A. Unified School District Vocational Nursing Program, (L.V.N.)

Licensure

• California Board of Registered Nursing, License Expires November 30, 2017

Skills

• Word, Excel, Outlook, Lotus Notes, Company based systems. Leader and mentor.