A large Blues plan was seeing significant outcome and cost variance as well as poor member experience due to retrospective denials and subsequent unplanned costs. The historical approach to utilization management was highly manual and reviews were of inconsistent quality and took too long. In addition, review staff were not equipped for success with their current medical necessity guidelines—lacking training and process fundamentals.
The session will present the process by which the plan redesigned their UM program with associated results. We will also discuss critical success factors on the path to value, including switching criteria vendors, as well as lessons learned for successful execution.
Attendees will learn:
Dawn Atkin BSN, RN, NE-BC, CPHQ, CMCN, CCP
Vice President, Medical Management & Population Management
Premera Blue Cross
Dawn Atkin is the Vice President of Medical Management and Population Management at Premera Blue Cross. She has been with Premera for six years and oversees the areas of medical review, clinical appeals, case management, chronic condition management, medical policy and clinical coding. Her health plan background includes delegation oversight and all aspects of medical management including disease management, chronic population management and complex case management for managed care and Medicaid plans. Dawn is a registered nurse, holds a bachelor’s degree in nursing, and has 20 years of diverse clinical experience. She is certified in healthcare quality, managed care nursing and chronic care coaching. She is a Certified Lean Leader and a board certified Nurse Executive.
Moderator – Carol Everhart, RN, MS, IQCI
Senior Clinical Consultant
Carol Everhart is an InterQual Senior Clinical Consultant at Change Healthcare (formerly McKesson Health Solutions). Her bedside experience includes Adult Critical Care, Emergency Room, Cardiovascular Services and Pediatrics. After 10 years of bedside nursing care, she transitioned to clinical data management and transitioned into Managed Care as the Director of Medical Management. Carol also has more than 10 years of experience as the director of Clinical Data Management and director of Clinical Informatics with two software companies. Her most recent prior leadership role was as director of Case Management and Quality Initiatives at Western Maryland Health System in Cumberland Maryland. In addition to her Nursing Degree, she holds a Bachelors of Art degree in Business Administration with a concentration in Computer Information Systems from the College of Notre Dame in Baltimore Maryland and a Masters Degree in Medical Informatics from Northwestern University in Chicago Illinois.