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CANDIDATE PROFILE
Name: Gail Hawkins
Last Updated: 2019-03-11
Email: gailhawkins@optimum.net
Phone #: 7324933960
Address: 10 Capitol Reef Road
Howell, NJ 07731
RESUME
»Gail Hawkins, MSW, LSW, LMSW
»10 Capitol Reef Road, Howell, New Jersey 07731
»732.493.3960 | 732.208.4432
»gailhawkins@optimum.net


»»»Qualifications Profile

Seasoned and performance-focused professional, with extensive experience in inpatient and outpatient management within managed care organization. Equipped with proven expertise in providing high-quality care, services, and treatment to patients; leading cross-functional and multidisciplinary clinical and non-clinical teams; and completing tasks within set-forth deadlines. Knowledgeable of HICFA, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Utilization Review Accreditation Commission (URAC), Office of Alcoholism and Substance Abuse Services (OASAS), Health Insurance Portability and Accountability Act (HIPPA), National Committee for Quality Assurance (NCQA), QUAR, IPRO, and Centers for Medicare & Medicaid Services (CMS) standards and regulations. Knowledgeable of diagnostic and statistical manual (DSM) and American Society of Addiction Medicine (ASAM) diagnosing and treatment. Effective at establishing and maintaining positive relationships with various patients, families, and other professionals. Proficient with Microsoft Office Suite (Outlook, Word, Excel, and PowerPoint), Inter-Qual Program ASAM criteria, and KCPC system.


»»»Areas of Expertise

Clinical Assessment
Problem Resolution
Crisis Management
Clinical Management
Administrative Support
Regulatory Compliance
Community Outreach and Social Work
Utilization Review
Staff Training and Development


»»»Professional Experience

»Horizon Blue Cross Blue Shield of New Jersey | West Trenton, NJ
»Supervisor SW/RN 2016–Present

*Care, Case and Disease Management Department | Community Based Case Management Team
Guarantee the fulfillment of departmental productivity goals regarding quality, timeliness, accuracy, and consistency of medical decisions through management, assessment, and coordination of daily activities of the unit.
*Take charge of ensuring staff’s compliance with regulatory requirements, as well as understanding and adherence to best practices, professional standards, and internal policies and procedures.
*Assess workflows, review compliance reports, identify and address areas for areas for improvement, and execute cost-saving and revenue generation initiatives.
*Act as a main liaison among medical directors, management leadership, and staff; resource to members, providers, and non-clinical staff; and a subject matter expert on difficult and complex matters.
*Create key performance indicators to assess level of service for both internal and external customers.
*Serve as a representative of the department on internal committees and contribute in special projects.
*Facilitating the management regarding regulatory, quality and accreditation activities arrangement;
*Lead and build top-caliber staff by providing feedback and coaching, along with evaluation of performance.
*Take part in meeting administrative cost objectives through budget preparation and observation support.
*Supervise both clinical and non-clinical staff of the community-based Case Management Team in fulfilling their daily tasks.
*Provide oversight with day-to-day activities of clinical and non-clinical staff within the Work from Home Program.
*Administer staff in managing cases for members with Medicaid, Medicare, Medicare Advantage, managed long term services and supports (MLTSS) and Commercial Plans.
Conduct planning, discharge planning as well as referrals to community services.

»Monmouth Medical Center | Long Branch, NJ
»Senior Psychiatric Social Worker, Inpatient Psychiatric Unit 2008–Present

*Deliver evaluative and inpatient mental health as well as substance abuse services to patients and families.
*Collaborate with community providers servicing the patients for discharge planning.
*Make suitable referrals to homeless patients for discharge planning and provide outpatient treatment or further inpatient treatment and nursing home placement to medically compromised patients.
*Create psychosocial evaluations treatment plans and medical records; as well as CEPP and continued commitment hearing reports for court hearing of committed patients
*Perform other complex tasks, including testifying with the committed patients at their court hearings; leading group, individual, and family therapy sessions; and taking part in quality improvement (QI) projects.
*Participate in daily patient rounds and treatment planning with staff physicians, focused on patient’s progress and continuous inpatient treatment.

»Amerigroup Company | New York City, NY
»Senior Utilization Review Manager 2012–2016

*Keenly assessed medical necessity in Kansas, New Jersey, and New York health plans by performing telephonic and electronic admission, concurrent clinical reviews for acute and sub-acute services for psychiatric as well as substance abuse patients through InterQual and ASAM criteria and KCPC system.
*Worked collaboratively with case managers to guarantee proper discharge planning.
*Communicated with the Facility Utilization Department in ensuring timely and appropriate discharge.
*Enhanced quality of care while lessening long hospital stays through review of clinical documentation and resource utilization.
*Evaluated utilization trends and inappropriate utilization of resources and submitted report to the medical director regarding quality of care issues.
*Performed daily consultation and clinical rounds with medical director which related to appropriate treatment plan.
*Enforced compliance with regulatory requirements of Medicare and Medicaid; and managed care systems.
*Presided over daily touch base meeting with Kansas Substance Abuse Team to guarantee proper distribution and prioritization of workload.
*Provided a document to the Substance Abuse Team to help them in assessing and authorizing cases on-time and to guarantee appropriate documentation.
*Rendered assistance in National Committee for Quality Assurance (NCQA) initiatives as well as in examining denied cases referred by the Appeals and Grievance Team.

»Team Lead Clinical Case Manager 2010–2012

*Carried out telephonic pre-and post-discharge phone contact with members and caregivers to deliver health education and discuss the discharge process to promote after care compliance and create care plans.
*Offered necessary assistance to members’ healthcare and behavioral referrals.
*Determined members with high-risk complications to be coordinated with healthcare teams for appropriate treatment and referrals.
*Ensured treatment compliance and provided necessary case management services through proactive interaction with member’s primary care provider (PCP) and mental health providers.
*Reviewed cases with the medical director and other health care professionals during complex case round for input on treatment for high utilizing members.
*Identified potential quality of care and advised appropriate departments in accordance with policy and procedures.
*Aided the medical director with the facilitation of daily clinical rounds.

»Access Counseling and Psychotherapy | Oakhurst, NJ
»Psychotherapist 2003–2017

*Attained effective intervention by incorporating psychological and social work theories into practice.
*Facilitated individual marital couples and family counseling sessions with children, adolescents, adults, and geriatric clients.
*Conducted initial psychosocial assessment with diagnosis, treatment, and discharge planning to clients with behavioral problems, including psychiatric issues medical conditions, substance abuse, abuse, and neglect.
*Developed high-quality clinical documentation for client records.
*Executed testing and provided feedback regarding the results.
*Held accountability in maintaining the confidentiality of confidential issues arising throughout the course of therapy.
*Oversaw master’s levels clinicians with treatment planning and discharge planning.
*Educated clients and family members regarding substance abuse and mental health issues.


»»»Earlier Career

Health Net/MHN | New York, NY
Team Lead | Senior Care Manager

Cornerstone of Medical Arts Center Hospital | New York, NY
Clinical Social Worker | Managed Care Coordinator, Admissions Department

Mount Carmel Guild Behavioral HealthCare Systems | Mt. Carmel Guild Special Hospital | Newark, NJ
Acting Director, Psychiatric Inpatient Unit
Admissions Screener, Admissions Department

South Amboy Memorial Medical Center | Location
Supervisor, Outpatient Mentally Ill Chemical Abusers (MICA) Day Program
Intake Coordinator
Emergency Room Crisis Screener


»»»Education

Master of Social Work, Minor in Alcohol and Other Drugs
Rutgers, The State University of New Jersey | New Brunswick, NJ
Graduated with Honors

Bachelor of Arts in Psychology, Minor in Biology
Rutgers, The State University of New Jersey | New Brunswick, NJ


»»»Professional Development

Licenses

Licensed Social Worker (LSW), State of New Jersey (Valid Until: 2020)
Licensed Master Social Worker (LMSW), State of Kansas, (Valid Until: 2020)
Licensed Master of Social Work (LMSW), State of New York, (Valid Until: 2020)
Licensed Clinical Social Worker (LCSW), Pending 2019

Certifications

Best Training and Handle with Care Certification
Advanced Integrated Case Management Certification
Integrated Case Management Certification
Advanced Certificate in Clinical Social Work (Graduated with Honors)
Basic Life Support (BLS) Certification
Cardiopulmonary Resuscitation (CPR) Certification
Certified Field Instructor, Seminar in Field Instruction (SIFI)


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