Bianca بزري

Analyzing risk portfolios of clinical records including; insurance case management records, provider records, pharmacy/ PBM records, claims paid, pending and other historical reports to set and predict risk cost in a fiscal period.

Completion of prediction by utilizing clinical experience and system risk programs.

Ongoing management of customer high risk/ lasered individuals in support from relationships developed with insurance case managers, account managers, brokers, claims adjusters and underwriters to support client portfolios to adjust the financial risk based on clinical updates in combining with clinical mastery.

Recommending to underwriters internal partnered solutions, tiered approaches in setting risk amounts to lower overall dollar risk.

Building out solutions with support of account team to implement risk reduction solution for clients and continue follow through on outcome on impactable high cost claimants and overall client portfolio.

Lead interpretation of analytic clinical data including HEDIS metrics in preventative health, company performance measures, clinical program satisfaction reviews, supporting performance guarantees, subject matter expert in clinical registration for proposals, reviews clinical operation model changes related to impacting ROI’s PG’S overall risk.

Analyze plan’s clinical profiles in Case Management, Utilization and Disease Management and pharmacy activity that are cost effective, educational conference calls on the clinical data presented, analyzes local plan’s performances and recommends revisions for ongoing contracting. Approves business plans in coordination with chief medical officer, legal and corporate leadership. Content expert in clinical analysis advisory groups, drive key stakeholders such medical directors, clinical design, informatics, IT, quality to identify health/cost management strategies and suggest providing pilot opportunities.

Client facing in presenting data with support from Health Economics. Reports clinical trends and compares benchmark and book of business data related to client. Drives solutions for elevated clinical metrics. Interfaces with sales to help support clinical questions related to programs and reported data.

Presented resources to complex patients on care providers, treatments and recommended treatment criteria. Collected clinical data and researched material to evaluate treatment options and helped coordinate with patients’ interdisciplinary team. Completed teaching and set up of designed treatment recommendations.
Analyzed cost of claims accrued for underwriting purposes for stop loss carriers. Researched guideline requirements based upon FDA, evidence-base practice, NCCN guidelines for internal underwriting/authorization protocols. Ensured leadership received reports with appropriate updates and notification of potential business risks by providing and maintaining standardized reporting of metrics, statistics, accomplishments, priorities and issues with complex patients.
Worked in data system in documenting care trajectory outcomes, ICD10 & CPT codes patients experience, responses of patients’/ family and care team’s involvement in care protocol.
Led weekly meetings with staff on flagged claims and interdisciplinary team solutions. Highly involved with Care Management nurses by reviewing prior-authorizations to mirror with claims system.
Developed process review of coding for nursing staff and internal doctors on appropriate billing codes for utilization of services. Worked with claims payer department for assuring appropriate coding when compared with clinical documentation.
Supervised team of 5 nurses, providing consistent and effective leadership within the resolution and research team, and maintained a high performing team for ever-changing company goals.
Led for transplant care and cancer care coordination. Generated policy procedures for cancer, transplant and pharmacy review processes.
Completed all employee management duties, including but not limited to, hiring, training, terminations, corrective active plans, reward and recognition, preparation and presentation of performance evaluations assuring compliance with policies, while creating an environment of performance and operational excellence with Director.
Ensured regulatory and legal compliance within department.
Recognized and promoted diversity in all aspects of resource management.

Assessed information in a timely manner to determine appropriate medical milestones on claims. Contacted medical professionals to clarify medical complexity. Formulated a clear and concise clinical impression based on clinical expertise to make an effective decision.
Reviewed the patient’s clinical documentation specifically care and safety policies while in-patient. Provided implementation on safety plan and appropriate policy restrictions in guiding return to work commitment to avoid risk.
Served as lead informational resource regarding environmental health and safety performance related to disability.
Chosen to be part of a select diversity and inclusion team exploring improvements in culture

• Charge nurse in post-acute rehabilitation unit for patients that require specialized nursing to those discharged from hospital ICU and medical surgical units.
• Provide all treatments, medications, updating the medical team by placing and receiving calls from medical professionals. Provide an appropriate course of action for patients. Create efficiencies for facility regarding communication strategies, developing feedback resources and skill development of staff.

Performed Nursing Assistant duties along with medication administration to patients.