| Candidate Information | | Title | Patient Care Health | | Target Location | US-AL-Fairhope |
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Click here or scroll down to respond to this candidateAccomplished health care professional with extensive experience in managed care and quality improvement supporting the healthcare delivery practice transformation with providers and staff to support physician practices. Dedicated and devoted to improving the quality of health care while reducing costs. Over five years of increasing responsibility with demonstrated ability to drive positive change and effectively manage communication with internal and external staff and customers.Proven history of increasing provider performance which addresses member risk assessment leading to improved quality care. Experience developing and implementing cost-effective approaches to minimize the organization's risks. Development of reports and execution of meetings to upper management to report risk findings. Exhibits exceptional communication and organizational skills, independent judgment, as well as leadership and supervision. Seeking a quality management position within healthcare.Key SkillsTechnical Writing HEDIS Measures NCQA Accreditation Data Analysis Customer RelationsQuality Management Data Analysis Medical Claim Appeals Provider Relations Business DevelopmentClinical Relations Compliance Network Management Medicare/Medicaid Training & LeadershipMS Office Suite Medical Claims Project Management Risk Management Program DevelopmentProfessional ExperienceNorth Shore Medical Center, Miami, FL Director of Clinical Quality Improvement June 2023-September 2023 (contract)Responsible for the operations of Quality for North Shore Hospital.Demonstrate productive and efficient management skills.Excelled in identifying and controlling critical cost elements; thereby promoting quality awareness and achieving the highest standard of excellence.Collaborates with staff and physicians to ensure compliance with policies and procedures and accurate implementation in accordance with patient care standardsEnsure overall compliance with nationally reported quality dataDevelops strategies and initiatives to ensure clinical quality indicator complianceCommunicates and collaborates with other departments in addressing clinical quality outcomesPerforms activities of interviewing, hiring, disciplining and termination.Develops, justifies and maintains departmental budgetsWorks in Collaboration with Physician Advisor to ensure appropriateness of patient care.Ability to identify staff learning needs, assist in planning and organizing orientation and Inservice training for employees. Ensures attendance of employee at mandatory education.Communicates and collaborates with other departments in addressing patient care issues and in formulating performance improvement activitiesParticipates in performance improvement teams develops and implements strategies to ensure PI complianceAttends and actively participates in medical staff and hospital committees and meetings.Collaborates with other disciplines, as appropriate, in the development of all policies and procedures as evidenced by seeking input and recommendations from department managers, medical staff, and legal counsel as necessaryEnsures clinical policies and procedures, processes, and documentation tools are in compliance with regulations and standards of practice, and ensures review of policies, procedures, and forms occurs on an annual basisEvaluates clinical services to ensure quality of patient care and to mobilize resources and intervene as necessary to achieve expected goals and desired clinical outcomes on a daily basisKeeps abreast of state and federal regulatory requirements and coordinates education for PI principles and regulatory standards within the facility based division, when indicatedMonitors incident reports for potential patient care related risk and opportunities for improvement, and assist facilities with root cause analysis and incident investigation, when warrantedHelp at Home, Remote Manager of Continuous Quality Improvement, October 2022-August 2023Manager Quality, Compliance, and Credentialing as it pertains to home health.Partner with clinical and operations stakeholders to build a Quality Assurance and Performance Improvement (QAPI) program that allows to proactively identify quality issues, take corrective action, and track & report the results of interventionsOversee internal and external aspects of provider credentialing, including managing external vendors and pursuing accreditation with The Joint Commission.Conduct, or oversee, ongoing internal quality and compliance audits. Provide high level executive summary to corporate on quality performance.Support Care Coordination team with clinical next back actions for high level clients.Gather, track, and trend data on provider quality for Quality Improvement Committee and Provider Operations use.Responsible for creating, implementing, disseminating, and updating policies and procedures that are aligned with local, state, and federal laws and regulations.Spring Health, New York City, New York Manager of Quality and Compliance, May 2022-October 2022Manager Quality, Compliance, and Credentialing departmentsPartner with clinical and operations stakeholders to build a Quality Assurance and Performance Improvement (QAPI) program that allows to proactively identify quality issues, take corrective action, and track & report the results of interventionsOversee internal and external aspects of provider credentialing, including managing external vendors and pursuing accreditation with NCQA.Conduct, or oversee, ongoing internal quality and compliance audits. Serve as the point person for all audits initiated by payers or employer partners.Gather, track, and trend data on provider quality for Quality Improvement Committee and Provider Operations use.Responsible for creating, implementing, disseminating, and updating policies and procedures that are aligned with local, state, and federal laws and regulations.Responsible for commercial contracting as it pertains to QualityEmory HealthCare Network Hospital, Atlanta, Georgia Practice Transformation Coach, Jan. 2022 May 2022Subject Matter Expert (SME) for Accountable Care Organization as it pertains to electronic quality care measures, educating providers on Key Performance Indicators (KPIs) measures to audit annual improvement and seek to maximize quality payout bonus awards.Examine and analyze root causes of financial and quality underperformance and communicate remedial strategies and intervention work plans to providers and key practice staff.Develop, recommend and implement interventions at the practice and member level to improve clinical quality and operational efficiency, collaborate with practices to facilitate redesign efforts, support care teams, introduce population health management and support achievement towards improved financial, process and clinical outcomes.Develop and implement workflow redesign, including electronic health record (EHR) optimization, clinical documentation, billing practices, assessments, financial analyses and financial performance improvement to drive practice quality measures.Serve as a liaison to practices to provide on-site and remote assistance and facilitation to the clinicians, care teams and their associated practices to drive improvement in clinical quality and operational efficiency.Review and interpret summary data and performance reports such as pay for performance, HEDIS and medical cost ratio and develop data driven provider performance strategies.Actively participate in cross-functional teams to conduct work and resolve enterprise and regional issues.Emory HealthCare Network Hospital, Atlanta, Georgia Quality Improvement (QI) and Reporting Specialist, Aug. 2021 Jan. 2022Tasked with leading population health initiatives, provided clinical technical assistance and guidance to multiple program types including healthcare quality improvement activities for patients attributed to the Emory Healthcare Network (EHN).Included developing relationships with patients, primary care physicians (PCP) and health plans with the triple aim of improving health outcomes, constraining costs and improving key performance and quality indicators for patients.Partnered in the development and monitoring of QI initiatives designed to advance and sustain program goals, measure therapeutic components, assess the capacity of program staff and evaluate client outcomes.Provided technical assistance and guidance in the development, implementation and maintenance of quality assurance/improvement systems to program staff to improve productivity, problem-solving, performance and outcomes in alignment with the system vision.Provided subject matter expertise in the design and development of curricula, select training programs and workshops.Collaborated with program leadership and other departments to implement and monitor program improvement plans, corrective action plans and other measures resulting in external and internal audits.Independently audited and assessed the quality improvement data and activities to determine which methods of outreach result in optimal patient engagement, then self-implement process changes to improve outcomes.Responsible for all reporting of quality metrics to health plans contracted with the EHN, working closely with multiple health plans to identify HEDIS gaps.Monitored and analyzed assigned program quality metrics and all relevant data to ensure that they are compliant with all regulatory requirements and are incorporating quality improvement into their programs.Participated in research projects impacting patient care areas. As part of a patient focused service, promotes a supportive and healing environment.WellCare, Foley, AlabamaNetwork Performance Advisor, Dec. 2020 Aug. 2021Shaped provider behaviors to drive improvements in quality, provider and member satisfaction, optimizing member outcomes and maximizing shared savings.Key liaison between assigned strategic providers and various departments within the company including Quality, Operations, Finance, Health Services and other shared services departments.Established and led cross-functional communication and collaboration with internal departments to support provider performance and resolve barriers and challenges.Responsible for understanding the differences between Risk and Value-Based contracting and driving improved provider performance.Drove improvement in provider performance by analyzing, interpreting and communicating performance, financial utilization and quality metrics and reports.Planned and executed effective group meetings/discussions with proper objectives and outcome.WellCare, Lafayette, Louisiana Provider Relations Representative, Aug. 2019 Dec. 2020Liaison between the company and health care providers for purposes of recruiting, contracting, retaining, evaluating, maintaining and supporting their networks.Interacted as the primary contact to the provider community consisting of primary and specialty physicians and their staff to identify concerns and provide necessary training and continuing education.Identified network gaps and recruit qualified providers in accordance with client/payor/network needs.Detail oriented and knowledgeable on various fee schedule methodologies, including but not limited to Rresource-Based Relative ValueScale (RBRVS), per diems and global discountsWellCare, Lafayette, Louisiana Patient Care Advocate/Quality Practice Advisor, Jul. 2018 Aug. 2019Educated large physician practices on appropriate HEDIS measures, medical record documentation guidelines and HEDIS, ICD-9/10 and CPT coding in accordance with NCQA requirements.Documented details of visits and outcomes and reported critical incidents and information regarding quality of care issues to identify and plan opportunities for provider improvement.Collaborated with Provider Relations to improve performance in areas of Quality Assurance, Risk Management and Practice Operations coding and denials in action plans as agreed upon by providers.Delivered provider specific metrics and coached providers on gap closing opportunities identifying specific practice needs where WellCare could provide support.Acted as a member advocate between the member/family, physician and facilities/agencies ccommunicating with external data sources as needed to gather data necessary to measure identified outcomes.WellCare, Atlanta, Georgia Ombudsman Coordinator, Mar. 2016 Jun. 2018Cultivates relationships with community-based organizations, advocacy and community resources throughout the state to foster collaborative partnerships for services to our members.Acts as a representative between internal departments in fact finding, data gathering and problem solving for investigation and resolution of complaints; presents barriers to the Ombudsman Liaison for mitigation of risks or solution.Demonstrates exemplary customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness and other skills required to deescalate situations as they arise.Assists the State, The Department of Public Health and Medicaid/Medicare, in finding solutions to resolve high level member complaints.Analyzed cost effectiveness and risk analysis for patient care, reported on trends that may influence the development of resource strategies within the social safety net.Education, Licensing, Certifications & TrainingB.S., Criminal Justice and Psychology, Westfield State College, Westfield, Massachusetts, May 2006A.S, Registered Nurse, Coastal Alabama Community College, Fairhope, Alabama, Currently attendingLicensed Social Worker Associate (LSWA), Board of Reg. of Social Workers, Boston, Massachusetts, exp. April 2025Mediator Certification Program, Georgia Office of Dispute Resolution, Atlanta, Georgia, exp. Dec. 2024Basic Mediation Skills Training, Ddomestic Practicum courses, Justice Centers of Atlanta, Sep. 2015Forensic Criminology, Graduate Certificate Program, University of Massachusetts Lowell, Mar. 2015 |
