SUMMARY:

Results focused, accomplished and collaborative clinical nurse executive in health plan and service organizations. Strong industry knowledge of health insurance, managed care, Medicare, and Medicaid. Developed strategies to improve operational efficiencies and optimize revenue opportunities. Developed innovative management plans to maximize productivity, quality, and organizational excellence.

EXPERTISE AREA:

• Value Based Care Models
• Process Improvement
• Team Leadership
• Care Management
• Operations Management
• Project Management
• Client Services
• Organizational Development
• Change Management
• Networking
• Training/Mentoring
• Fraud Management
• Bundled Payment
• Population Health

PROFESSIONAL EXPERIENCE:

Confidential, Fairfield, CT

Adjunct Professor

Responsibilities:

• Disease Management and Outcome Assessment
• Evidence Based Practice.

Confidential

Independent Healthcare Consultant

Responsibilities:

• Designed and Implemented Obesity program (Reduced clinic BMI - rehospitalizations).
• Medicaid redesign 9 Health Homes each accredited with level III Confidential (2017) (Integrated models).
• Designed care coordination and care plan platform for a software company (application: mobile devices/EHR)
• Reorganized a national health plan’s business and clinical operations to meet state/CMS requirements.
• Change agent on behalf of a national health plan to develop and enforce CAP, for deficiencies.
• Designed a Care Coordination Infrastructure for population health (DSRIP) for a software company.
• Manage multiple clinical projects under the Medicaid 1115 Waiver for DSRIP (Strategies intended to move the organization from volume to value-based care).
• Developed multiple New York State Home Care Agencies to Care Management organizations that are now supporting Health Plans (Dual eligible/ High-Risk Chronic) and Self-Insured Payer groups. Developed and Implemented Interdisciplinary Team, Care Management, Utilization process, budgets, and quality program.
• Identified Medicaid/Medicare Fraud 3 organizations (150million, 50million, 20 million) self-reported developed a corrective action plan.
• Developed education for assessment team focused on getting the best diagnosis for risk-adjusted premium rate setting.
• Created Integrated and accreditations approved programs in two organizations Managed Long Term Care (MLTC) Program to Fully Integrated Duals Advantage (FIDA). Inclusive of developing of medical and case management policies, procedures, and guidelines; and developing clinical management guidelines. Designed Clinical Indicators along with HEDIS reporting structure into the quality program.
• Developed infrastructure for DSRIP to integrate into an existing ACO/ Confidential /MLTC
• Developed and implemented a hospital Intern program to support coaching of members.
• Expanded Care Manager analytics for MLTC program to help guide cost and reduce the PMPM.
• Developed Behavioral Health Care Coordination program for FIDA/PACE/MLTC
• Established 4 Models of Care NCQA approved, for organizations that were looking to become a Medicaid Licensed agency for MLTC .
• Developed Clinical Documentation modules for hospital/clinics
• Developed Curriculum for coding improving rate adjustability
• Restructured and Integrated major hospital systems case management and Confidential program
• Software development for EMR/EHR’s to meet documentation: metric/HEDIS/regulatory requirements.
• Proven cost savings in each program developed.
• Re-directed Medicaid population back to PCP and in-network providers.
• Network Provider training developed for specialty programs.
• Budgeting multiple projects came in under budget.
• Developed infrastructure for Confidential /MU/PQRS/MIPS/ACO
• Created innovated strategies for market growth in each project.

Confidential

Responsibilities:

• Implemented deliverables
• Developed analytics and process flow that established assessment and implemented project phases
• Supervised teams and co-workers to coach and mentor staff
• Project delivered ahead of schedule

Confidential, New York, NY

Enhanced Care Initiatives Consultant

Responsibilities:

• Designed Integrated and implemented care model consistent with promoting collaboration, coordination, and communication across disciplines and departments within the Program. Care Manager accountable for Medicaid Medicare and commercial business throughout the continuum
• Created an algorithm monthly PM/PM for teams to review and develop protocols to lower cost but at the same time delivers care.
• Reduced hospitalizations 19% in a 6 -month period
• Management function that promotes objective and systematic monitoring and evaluation of the Care Management service
• Developed for the Payer groups (Self- Insured clients) Disease management and care management programs. (Metro Transit Authority New York State, Bakery Union) reduced days out of work and more compliance with wellness.
• Deployment of Wagner Chronic Care Model.
• Organized and advised the staff (LPN’s, RN’s NP’s SW, Care Coordinators, and Managers) on all operations related to the delivery of clinical care in accordance with established policies, state, and federal regulatory requirements.
• Developed implemented and communicated cost-effective, quality comprehensive nursing care across all programs.
• Participated in the recruitment, interviewing, selection, orientation, and evaluation of all new clinical staff.
• Developed documentation standards to support the severity of disease improved HCC coding.
• Built a program based on cost trend analysis with protocols for Care Management to empower patients to take a more active role in transition through the continuum reducing rates of subsequent hospitalization.
• Developed cross-site communication utilizing Electronic Health Record when available.
• Designed effective medication reconciliation process engaging Pharm. D.
• Reduced readmissions and ER admissions by 26% in 2 boroughs within 6 months.
• Program inspired 1100 Medicaid recipients to utilize Primary Care Physician (PCP) versus emergency room (ER).
• Design supports other programs to achieve for physicians, CMS, and Health Plans: Meaningful Use, HEDIS, Stars and Accountability Care Organization (ACO).
• Developed Care Management support.
• Developed tools for: Patient education/Performance measures/Auditing and reporting
• Workflows were designed to sustain Medical Home beyond the project.
• 900 Medicaid members previously utilizing the Emergency Room as primary care physician (PCP) now engaged in self-care model with a PCP.
• Developed templates for Electronic Health Record (EHR) (McKesson, GE, Meditech, Eclipsys, eClinicalworks, Centricity) Documentation, Quality Measures, and coding specific to each practice.
• Worked collaboratively with vendors to implement EHR’s into the practices.
• Reduced ER and Hospital admissions increased patient compliance.
• Presented Medical Home outcomes to CFO, CEO,CMO and physicians

Confidential, New York, New York

Confidential Consultant

Responsibilities:

• Implement and manage teams in hospitals across the country on various revenue cycle and Clinical Documentation Programs.
• Follow up with Clients to ensure satisfaction with product/program; troubleshoot when necessary
• Work with Sales team to introduce products and begin the sales process
• Collaborate with Hospital to define/develop tools for efficient/effect charting /billing
• Defended Hospitals against the RAC reviews.
• Developed strategies to improve CHF and oncology outcomes to reduce hospital days and prevent re-admissions.
• Project Managed Confidential assessment resulted in increased business for Case Management and Revenue Cycle.

Confidential, New York, New York

Onsite Patient Advocate

Responsibilities:

• Researched data of major medical centers to provide strategies to improve patient outcomes by utilizing out-patient services with results showing financial impact.
• Understanding Lines of business in the insurance industry (Medicare, Medicaid, Fully Insured, and ASO) business along with all benefits available to assist with developing the best care possible for patients.
• Comprehensive familiarity of State and Federal regulatory requirements for the health care system in whole, including accreditation, JCAHO and NCQA

Confidential, Tarrytown, New York

Project Manager

Responsibilities:

• With a team developed, planned, and executed Telehealth Disease Management Programs tailored to individual organizations nationwide.
• Major Client Veterans Administration Hospitals developed CHF protocols and program for Telehealth nationwide and integrated into their Electronic Health Record system.

Confidential, Nashville, TN

Provider Service Manager

Responsibilities:

• Direct Calling on primary care physicians and cardiology offices to demonstrate how Disease Management programs were designed to supplement and support physician care.
• Collection of clinical data was used to identify patient behavior and interact with physicians to show how improvement of the quality of care directly impacts the outcomes of chronically ill people.
• Identified quality and risk issues that arise during a physician visit and developed an action plan with continuous monitoring till issue were resolved.