Qualifications Profile

• over 20 years of healthcare experience, specifically within the Medicaid and Medicare markets. She is an innovative and performance-driven Sr. Managed Care leader with a solid and progressive career leading the development and delivery of policy, process, and operational improvements in highly competitive and regulated marketplaces. Demonstrated expertise in the collection and analysis of performance data and the development of standards and practices that lead to increased productivity, customer satisfaction, and profitability. A natural leader with the proven ability to guide and mentor staff, work across functions and departments, and leverage resources to achieve organizational goals.
• Experienced and successful in working with state and federal regulatory groups on compliance matters.
• Expertise in Quality Improvement and Customer Service program development and management in the managed care arena.
• Strong project management, communication, and executive presentation skills, with the proven ability to remain effective and productive under pressure.
• Proficient with productivity software and tools including Microsoft Office Word, Excel, Outlook , Project, Access database development, and various quality reporting and healthcare delivery systems.

Key Skill Areas Include:

• Program/Project Management: HEDIS Project Management, Performance Management, Communications Management, Quality Management, Customer Service/Outreach Program Management, NCQA accreditation project management, EQRO audit management, Risk Management, strategic planning, think tank facilitation, barrier/root cause analysis workgroups, Six Sigma protocols DMAIC
• Care Coordination: Program design, workflow development and restructuring within managed care programs, safety net programs and Federally Qualified Health Clinic systems, staff/ process oversight, process improvement development, evaluation of outcomes, establishment of partnerships with providers
• HealthCare Management and Policy: Managed Care, Balanced Budget Act, Meaningful Use, Accountable Care, Quality Reporting, Electronic Medical Records, Medicaid, Medicare Advantage and DSNP , Public Policy

Professional Experience

Confidential

Sr. Director of Quality and Accreditation

• Provides executive level leadership for all quality functions, with full accountability for compliance with state and federal requirements relating to clinical quality for a startup managed care organization launched July 2013 . Serves as organizational lead and resource for NCQA, HEDIS, external quality review EQRO activities and other contractual requirements. Collaborates with Regulatory Compliance Officer/Legal Counsel to perform internal monitoring activities. Facilitates weekly Operations and Quality workgroup meetings and quarterly Quality Executive Committee meetings. Oversees the organization's Grievance and Appeals, EPSDT, and Early Interventions program units as well as other quality department personnel. Represents the organization at external meetings hosted/facilitated by the District of Columbia Department of Healthcare Finance.
• Performed organization-wide contract gap assessment ensuring that all departmental policies and programs were fully implemented prior to 90-day assessment.
• Coordinated/organized organization's 90-day assessment which included compiling substantiating documentation to demonstrate successful implementation of programs and facilitated mock-interviews to prepare staff for the on-site review.
• Launched HEDIS program and successfully coordinated/facilitated the organization's first annual HEDIS compliance audit.
• Developed programs and policies as part of the organization's first NCQA accreditation process awaiting date for Interim accreditation survey

Confidential

Director, Quality Improvement

• Managed all quality functions, with full accountability for compliance with state and federal requirements relating to clinical quality matters. Works across internal functions and with physician and vendor groups to resolve quality of care issues. Served as organizational resource for NCQA, HEDIS, STAR ratings and other external quality review/contractual requirements. Provided extensive reporting on quality management issues through case summaries, medical record reviews, and regular reporting. Performed qualitative/quantitative analysis to address clinical quality outcomes. Coordinated external quality reviews and performance validation audits for source code programming of clinical studies data. Facilitates data analysis workgroup meetings. Coordinated Quality/physician advisory and Service Quality Improvement Committee meetings.
• Developed programs and policies as part of a successful NCQA New Health Plan accreditation process 3-year accreditation awarded - 2009 and NCQA full accreditation Commendable rating awarded 2012 .
• Managed annual HEDIS activities and developed/implemented initiatives resulting in significant improvements in 80 of critical financial impact measures.
• Organizational lead on district-wide collaborative to address healthcare disparities for individuals with adverse perinatal outcomes. Worked with national NICU team to coordinate activities resulting in a 57 decrease in NICU average lengths of stay within one year.
• Functioned as the Quality lead for successful collaboration with community-based providers to improve access to care for Medicaid/medicare dual special needs population resulting in a .5 increase in STAR rating within one year.
• EPSDT/Outreach Manager
• Managed the Early and Periodic Screening, Diagnosis and Treatment EPSDT , IDEA, Early Interventions and Preventive Health Outreach programs. Developed and implemented initiatives designed to improve EPSDT and other Preventive Health Screening rates through member and provider education and outreach. Initiatives are aligned with the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Healthcare and the United States Preventive Services Task Force Guide to Clinical Preventive Services. Tracked education and outreach efforts and develops monthly and quarterly regulatory reports. Effectively managed a team of Outreach Coordinators and collaborated with Provider Advocates and Health Services staff to ensure coordination of activities and services which positively impacted member screening rates.
• Implemented outreach initiatives and partnerships with community based practitioners and FQHCs to improve Early and Periodic Screening and Diagnostic Testing EPSDT compliance rates resulting in a 24 improvement in 3 months.
• Developed and implemented an adolescent well care project in partnership with community based practitioners and FQHCs which resulted in a 25 improvement in adolescent compliance with EPSDT requirements within 6 months and 2 improvement in the adolescent well care HEDIS domain.
• Facilitated think tank on Early Interventions Medicaid special needs program using Six Sigma DMAIC approach, in which over 1million in regulatory sanctions was avoided by identifying and mitigating barriers to contract compliance.

Confidential

Senior Consultant

• Performed audits supporting CMS in its oversight of the Medicare Part C and Part D programs and made key contributions in identifying Medicare marketing violations. Served as an integral part of the team supporting CMS with the regulatory audits of Medicare Advantage Organizations MAO and Part D Sponsors. Supported both CMS Central Office and Regional Office divisions in all phases of the audit lifecycle, including: conducting audits, identifying irregularities through data analysis, and validating sponsor self-reported data. Evaluated health plan data related to a variety of CMS requirements around payments, true out-of-pocket costs, enrollment, claims, coverage determinations and appeals, among several other regulated areas of the Prescription Drug Benefit and Medicare Advantage programs. Reviewed of health plan marketing practices to include review of the content of Medicare print advertisements and secret shopping of marketing events.
• Conducted detailed analysis of the Medicare Modernization Act MMA , the final Part D regulations and all CMS issued guidance to evaluate health plan compliance with Medicare marketing requirements.
• Provided editorial recommendations in updating the CMS Part D Audit Guide.
• Produced weekly outcome reports to CMS in the absence of the System for Compliance Analysis of Medicare Print Advertisements SCAMPA database administrator.
• Developed a standardized operating procedure for the reporting process.
• Contributed content and editorial recommendations during the drafting of the comprehensive audit findings reports for each audited health plan.

Confidential

HEDIS Quality/Project Manager

• Improved annual dental visit rates by 45 within 6-months by identifying data mapping issues leading to successful merger of supplemental dental data into HEDIS extract.
• Chaired meetings with local managed care organizations MCO'S resulting in implementation of an effective data exchange mechanism to support mental health HEDIS requirements between the MCO'S, Department of Mental Health, and the Medical Assistance Administration. Gained NCQA approval for use of supplemental mental health data.
• Participated in a successful NCQA certification process awarded in Utilization Management and Credentialing . Successfully managed key projects that led to full HEDIS submission and fully compliant designation for annual HEDIS audit.
• Directed all HEDIS activities including: data collection, qualitative/quantitative analysis, reporting, trending, identification of opportunities for improvement, devising/implementing/evaluating strategies to improve quality of care/service, barrier/root cause analysis, satisfaction surveys and completion of QIA forms. Provides corporate oversight of annual HEDIS project, budget, and vendor delegation. Developed organizational strategic plan regarding annual HEDIS activities and adjusts timelines as deemed necessary. Educated internal staff and external providers regarding HEDIS requirements and elicits cooperation for successful implementation. Maintained expertise in Federal/District of Columbia statutes and regulations, Delmarva guidelines, contractual obligations, and HEDIS specifications. Coordinated annual HEDIS audits. Chaired the organization's Operations Committee.
• Developed and implemented initiatives resulting in the following overall improvements in less than one year: Adolescent Immunization Status- 11 Appropriate Testing of Children with Pharyngitis- 53 Prenatal/Postpartum Care- 15 CAHPS Care Coordination CCC Composite- 8 .

Confidential

Director, Quality Management

• Directed all quality functions, with full accountability for compliance with state and federal requirements relating to clinical and operational matters. Supervised and trained a staff of five and managed an operational budget of 600K. Worked across internal functions and with physician and vendor groups to resolve issues. Facilitated online quality program audits. Coordinated risk management issues with legal counsel and the Chief Medical Officer. Served as organizational resource for NCQA and other policy/regulatory/contractual requirements. Provided extensive reporting on quality management issues through case summaries, medical record reviews, and regular reporting. Supervised the complaint resolutions unit.
• Developed programs and policies as part of a successful NCQA accreditation process 3-year accreditation awarded . Improved annual quality review scores by 32 within one year. Successfully managed key projects that led to full HEDIS submission for 2005 and 2006.
• Consistently kept the organization ahead of regulatory schedules by developing and monitoring timetable for quality activities and reporting.
• Developed a strong, cohesive and productive audit team, with all individual member's departments receiving high-level annual performance reviews.
• Developed/ implemented organization-wide Patient Safety plan in accordance with regulatory requirements.

Confidential

• Provided comprehensive direction and guidance to the Customer Service Department by ensuring timely and effective resolution of member and provider issues regarding benefits, claims status, networks, complaints and grievances. Established departmental goals and objectives and tools to measure outcomes. Developed and managed departmental budget of 450K. Developed and implemented educational and informational programs for members. Provided analysis and reporting on customer service matters to the Quality Management Committee and worked collaboratively on improvement initiatives. Chaired the Member Advisory Committee.
• Developed a system-wide process and methodology to track and manage customer complaints in compliance with state and federal requirements.
• Created an automated complaint tracking system that improved customer satisfaction with the resolution process by 50 within 12 months of implementation.
• Established a plan to merge provider services and member services that led to an 18 decrease in the call abandonment rate within one month of implementation.
• Drove a set of policy and process improvement activities that improved external customer service review scores by 25 from June 2002 to September 2003.

Confidential

• Manager, Regulatory Compliance 1999-2001 Promoted to senior role in recognition of success in improving quality. Liaison between the corporation and all external regulatory agencies at the state and federal level. Worked with department managers to ensure timely compliance with all reporting requirements. Organized and chaired the company's first Consumer Advisory Board. Managed two full time compliance personnel. Represented the corporation in meetings with regulatory agencies. Assembled documentation and provided reporting for annual audits and internal reporting. Provided internal management and staff with updates on regulatory matters. Developed and managed the annual 350K departmental budget. Member of the senior Quality Management Committee. Served as a policy resource for senior management and all staff.
• Developed and implemented corporate compliance plan and code of ethics, resulting in a 20 decrease in claims interest payments for calendar year 2000. Improved staff accountability through ethics training. Recommended the implementation of claims auditing software to further increase processing efficiency.
• Organized compliance and quality assurance training program for new employee orientation.
• Significantly raised standards and compliance levels and improved the profile of the company with state regulators through close attention to quality improvement measures and related regulatory requirements during 3-year receivership.

Analyst, Quality Management

• In a fast-paced start-up operation, coordinated a range of activities involved in identifying, researching and analyzing clinical and administrative issues with the potential to adversely impact the quality of healthcare being delivered to plan participants. Performed extensive data analysis and quality review reporting to senior management, providers, and external review organizations. Delivered key improvements that turned around an under-performing organization.
• Increased quality standards through the development and implementation of an automated Risk Management Program and Quality Review tracking and monitoring. Trained Quality Management staff on the databases.
• Developed and implemented a corrective action plan that raised the recorded grade for complaint resolutions as determined by the Maryland State Department of Health and Mental Hygiene from D to A within six months.

Confidential

Grievance Coordinator

• Investigated and resolved provider grievances as part of the quality assurance and utilization review process. Performed research and trend analysis of statistical data and presented results and recommendations for policy changes as appropriate. Designed and implemented process improvements that improved overall effectiveness and efficiency.
• Developed tracking sheet used by onsite nurses to document hospital staff grievances.
• Developed and implemented corporate Grievance review policy and procedure.
• Reduced unit grievance backlog by 50 within 12 months, contributing to stabilization of provider network.

Confidential

Healthcare Facilitator

• Performed utilization and case management services through precertification and retroactive claims reviews. Served as liaison between claims and utilization review departments.
• Performed medical chart reviews as part of a successful NCQA accreditation process.
• Decreased Medicare patient hospitalizations by 25 in 1996 by coordinating home nurse evaluations for high-risk patients.
• Additional Experience 1990-1997 : Industrial Hygiene/Environmental Health, US Air Force active and reserve duty.