OBJECTIVE

• I desire a management position in the health care industry.

SUMMARY

• Accomplished analytical Quality Improvement Expert with proven track record driving organizational objectives in large scale environments.
• Versed in all areas of health care operations and QI including Compliance, Process Improvement, and internal and external audits, as well as, Risk Management and database utilization ensuring accuracy and efficiency across multiple sites. Solid team player with strong customer relations skills ensuring client satisfaction.

AREAS OF EXPERTISE

• Regulatory Affairs
• General Management
• Clinical Quality Improvement
• Strategic Planning
• Research and Development
• Analytical
• Project Management
• Compliance

PROFESSIONAL EXPERIENCE

Confidential, Southborough, MA

Product Manager+Sr. Business Analyst

Responsibilities:

• Partner with clients and internal implementation/developers and analysts to gather all requirements to formulate HEDIS related business process specifications and translate into application functionality, understanding value proposition of the project, deciding when to advocate and when to compromise to arrive at mutually acceptable solution.
• Translate business requirements for projects (multiple technology modules and systems) into functional specifications.
• Document workflows and results of business analysis and obtain sign - off from client on specifications
• Assist technical teams in translating application functionality into application architecture and the production of a System Functionality document
• Communicate business directives, goals and needs to the technical team and serve as a client interface for managing user expectations and client satisfaction
• Design and execute test plans, tracking defects and getting them resolved to ensure that business requirements and functional specifications are tested and fulfilled
• Assist in developing User Help Documents, User Guides, and Release Notes and training materials for multiple product lines
• Participate and/or execute the multiple stages of testing (i.e. Functional, Integration, Installation, Performance, Regression)

Confidential, Hopkinton, MA

Clinical Quality Analyst

Responsibilities:

• Collaborate effectively in clinical development and operations, regulatory affairs, research, and other relevant functional areas to jointly identify areas for quality improvement and propose specific quality improvement measures including monitoring Clinical QI effectiveness checks for process improvement.
• Ensure appropriate documentation, reporting and closure of clinical compliance issues. Escalate compliance issues to Quality Management and relevant department management.
• Plan and undertake a range of Quality Audit activities, including internal audits of Quality departments, audits of health plans, including but not limited to, vendors, internal clinical quality systems and processes, audits by external quality investigators, to verify adherence to Good Quality Practices. Generate audit reports and evaluate effectiveness.
• Manage the Medicaid Medical Record Review Vendor Management Program..
• Conduct Quality review of Corrective Action Plans (CAPs) of health plans for regulatory submission and tracking development and implementation.
• Provide QI Compliance support to the HEDIS Data Management program.

Confidential, Oakton, VA

Clinical Quality Analyst

Responsibilities:

• Define business processes and troubleshoot various quality improvement operations
• Anticipate customer needs and proactively develop solutions to meet them
• Conceptual analyses of quality improvement projects of Long Term Care Medicaid Health Plans and prepare reports and submit to State for review
• Research and recommend marketing materials for health plan members and providers and work with appropriate departments in improving the quality of materials as required
• Perform interventions for non-compliant health plan members and providers and suggests best practice processes for the affected health plans
• Manage multiple projects for Long Term Care Member Satisfaction and Provider Satisfaction Surveys with outside vendors and Health Plans
• Create and track technical specifications for Long Term Care Plans
• Manage and report Provider Profile Project with health plans and State Agencies

Confidential, Oakton, VA

Director, Quality Improvement & Compliance Officer

Responsibilities:

• Facilitate the COA accreditation and review process for the organization
• Provide leadership and implementation of the organization’s Quality Improvement Plan, including, but not limited to:
• Assisting programs with establishment of Annual Data Collection Systems and oversees the collection of such data
• Coordinating the development and implementation of outcome-based goals for each program/ division of the organization
• Ensuring record review and improvement processes
• Participate in the development of agencies Strategic Plan, Policies and Procedures as related to Quality Improvement and Risk Management. Insure that these policies and procedures, such as Client Confidentiality, are followed
• In tandem with Program Vice Presidents design, manage, revise, maintain and distribute the organization’s Service Delivery Policy and Procedure Manual
• Create, maintain and manage the organization’s Administrative Manual
• In coordination with Human Resource Department, provide leadership in New Hire Orientation, establishment of Annual Training goals and plan, and Annual Review of Personnel Policies and Procedures
• Attend key Board meetings to report of activities associated with Quality Improvement Plan and Compliance/Risk Management Report
• Review legal, liability concerns from staff to ensure compliance with COA. Inform and coordinate all Risk Management activities with agency Senior VP of Finance & Administration
• As designated by the President/ CEO, assumes responsibility as Agency Compliance Officer
• Responsible for the overall development and implementation of the agency’s Risk Management Program.
• This includes regular review of insurance coverage, policies and procedures designed to minimize risk to clients, staff and the agency and the Office Safety Inspection Report

Confidential, Woodland Hills, CA

Compliance Analyst / Project Management

Responsibilities:

• Ensure that the organization’s Quality Improvement processes are accurate and compliant with applicable NCQA Standards/DMHC regulations/CMS requirement/DHCS categories
• Consult and resolve different compliance and quality improvement issues by researching regulations and rulings of regulatory agencies
• Manage the Medical Management Policy & Procedures project of all Medical Management departments of Confidential of California and Confidential of North East, ensuring thatthe policies are compliant with different regulatory requirements and are reviewed annually within the 14 month period of NCQA compliance requirement
• Monitor and manage the Corrective Action Plan (CAP) project as required by Department of Health Care Services of California for all State Health Programs projects
• Monitor, manage and review all Quality Improvement initiatives (within and outside of committees) and completion of the projects within the 14-month period as required by NCQA for all product lines and for both California and North East
• Conduct audits, inspections, or investigations of quality and utilization of services and may assist in promulgation review and revision of state licensure regulations operational guidelines.
• Organize and run the quality improvement committees (e.g. State Health Programs, Commercial and Medicare, Dental State Health Programs, Specialty Network Committee etc.) and monitor the compliance of quality improvement initiatives, programs and activities through these committees and notifies the committee of any irregularities or out of compliance issues
• Provide training to all Medical Management Departments on Compliance