PROFESSIONAL EXPERIENCE:

Director Provider OPS/Contracting

Confidential, Washington DC

Responsibilities:

• Responsible for the overall (customer service) management of contracted providers within the Confidential healthcare network
• Supervision of five (5) employees, to include a Contracting Manager
• Development and administration of a budget that provides for the attainment of agreed upon goals and objectives in accordance with approved plans, providing efficient and cost effective utilization of services
• Manage and improve network management operations to achieve or exceed performance standard budgets
• Create plans of actions to improve performance of provider contracts
• Negotiate delegated claims, credentialing, and other delegated provider agreements
• Manage required regulatory compliance for provider networks and compensation
• Analysis and reporting of financial information specific to provider contracts

Clinical Quality Analyst

Confidential, Washington DC

Responsibilities:

• Monitoring and reporting of quality indicators to organizational committees
• Methodology design and data interpretation, to include clinical and statistical analyses of health plan data
• Assist with the organizational strategic plan, quality improvement plan, and quality program evaluation
• Development and monitoring of corrective action plans when necessary, monitoring of organizational compliance until issue is resolved
• Design and implementation of detailed quality improvement project plans
• Project Manager NCQA project as assigned
• Annual reviews/inspections of provider nursing agencies, provider offices, and in Confidential t/out Confidential t psychiatric facilities
• Project coordinator Confidential Asthma Pilot

Clinical Quality Coordinator

Confidential, Washington DC

Responsibilities:

• Maintain quality program documents to include: QM Program Description, QM Work plans QM and Organizational Polices and Procedures.
• Data analysis of quality measures
• Development and maintenance of administrative databases in support of quality improvement initiatives
• Facilitation of the Quality Management Committee, Quality Oversight Committees, and Physician Advisory Committee
• Participate and collaborate with staff to focus on and meet required submissions of reports related to the National Committee for Quality Assurance (NCQA), and other related organizations which measure health plan quality.

Project Manager Quality Improvement

Confidential, Bowie Md

Responsibilities:

• Create and maintain client implementation plan and schedules.
• Comprehensively manage assigned client relationships.
• Liaison between Confidential and Confidential clients.
• Foster and support business development opportunities specific to quality improvement projects.

Manager Quality Improvement

Confidential, Baltimore Md

Responsibilities:

• Assist the QI director with the revision and/or the development of the QI Program, QI evaluation, and work plan.
• Investigation of quality of care cases working in conjunction with Compliance.
• Develop quarterly reports related to reported quality of care cases.
• Assist the QI director with annual audits: to include, but not limited too: HEDIS, NCQA’s annual structure process submission for SNP plans. CMS annual audits.
• Interface with all internal departments and markets to ensure compliance to the QI program policies and procedure.
• In conjunction with the QI director, serve as a liaison between the company and outside agencies for clinical quality activities.
• Assist with clinical data collection, analysis, reporting and follow - up for CMS and NCQA.
• Provide continuous quality improvement to all employees.
• Assist the QI director with coordination of the Quality Improvement Committee.

Clinical Appeals Coordinator

Confidential, Phila Pa

Responsibilities:

• Collaboration with physicians, nurses, and outside agencies and other members of the Confidential t’s healthcare team to facilitate maximum reimbursement for the network while complying with Federal, State, and Local laws and statues in to fraud, abuse and equitable business practices.
• Communicates with physicians to obtain clarification of orders, medical necessity and other required documentation for a successful appeals process.
• Maintenance of data in an organized manner to provide a basis for monthly, quarterly, or annual quality outcome reporting.
• Review of medical record documentation in conjunction with the health plans contractual obligation to the member group.
• Identifies billing and documentation issues resulting in claims denials, provides resolution to identified issues.

Clinical Documentation Specialist

Confidential, Phila, PA

Responsibilities:

• Review of clinical documentation specific to overall quality, accuracy, and appropriateness of clinical documentation.
• Review of clinical lab values and other significant clinical test, to insure they are appropriately documented in the Confidential t’s chart.
• Worked with physicians and all hospital departments to resolve documentation discrepancies to maximize hospital reimbursement.
• Clarification of clinical documentation standards via physician and in-service presentations.
• Assist with hospital wide JCAHO accreditation preparation, in conjunction with various hospital departments, specific to JCAHO clinical documentation standards.

Manager, Quality Improvement

Confidential, Phila PA

Responsibilities:

• Project Manager for Elder Health’s preparation of National Committee for Quality Assurance Accreditation of New Health Plan Survey 2005: Earned NCQA accreditation as a New Health Plan.
• Managed the Medicare Regulations/Guidelines specific to quality initiatives for Elder Health a Medicare Advantage Health Plan.
• Project Manager for Annual HEDIS reviews of contracted providers for NCQA designated quality indicators.
• Conducted analysis and reporting of various Medicare Healthcare audits: HEDIS, CAHPS, HOS and correlation of information into quality initiatives.
• Developed and coordinated the QI Work Plan, and annual QI evaluation.
• Collaborated with Network Development on performing bi-annual assessment audits, assessing standards for provider availability and accessibility and completing analysis on results.
• Assisted the Medical Director with problem specific Confidential audits.
• Monitored quality indicators, data analysis and prepared quarterly reports to the Quality Improvement Committee.
• Assisted President of Elder Health with coordination of the Quality Improvement Committee.

Medical Record Quality

Confidential, Phila PA

Responsibilities:

• Performed abstractions for Medicaid, Medicare, and CHIPS members.
• Directly responsible for HEDIS chart abstractions related to NCQA accreditation.
• Participated in HEDIS for Pool and Agency nurses.
• Reviewed incoming HEDIS abstractions and audits for inter rater reliability.
• Worked with various providers and medical record departments preparing for HEDIS.
• Participated in the development and implementation of the sickle cell case management project: duties included: utilization review, disease management, and case management.
• Performed utilization reviews of sickle cell cases determining appropriate level of care per Interqual criteria.

Case Manager

Confidential

Responsibilities:

• Responsible for disease management of members diagnosed with Confidential .
• Worked closely with Phila. Health Commissioner’s office to establish clinical protocols for Health Choices.
• Brokered the relationship between Americhoice and community Confidential organizations.
• Participated on the Persons with Disabilities Task Force in order to develop clinical vignettes to establish what constitutes medical necessity for Durable Medical Equipment.
• Liaison between Americhoice and community advocates serving the disabled population.