OBJECTIVE

To obtain a Vice President of Medical Management or Vice President of Clinical Operations Position with a major health plan

SUMMARY

• Executive Healthcare Leader who combines over 20 years of clinical, operational, quality, and healthcare management experience in the public and private sectors, specializing in Utilization Management, Case Management, Disease Management, and Quality/Process Improvement:
• Clinical and Operational Healthcare Management experience in public and private sectors, including Medicare, Medicaid, TRICARE, and Commercial populations.
• Former Confidential Senior Vice President of Accreditation who spent over 10 years actively leading the development, beta - testing, and review process of over 16 national accreditation programs including the nation’s first Nurse Advice Line, Case Management, Claims, and Health Web Site Accreditation Programs. Led the transition of Confidential accreditation application process to a more cost-effective, on-line submission process. Designed and operationalized the first national managed care accreditation compliance monitoring program. Championed national quality initiatives and the adoption of managed care industry best practices.
• Confidential /NCQA Accreditation Consultant and HEDIS Subject Matter Expert with extensive Medicare and Medicaid Regulatory/ Compliance experience, including Medicare Model of Care and Special Needs Population (SNP).
• Innovative, Progressive Thinker and Industry Leader with current experience in working with emerging national clinical models, including patient-centered medical homes (PCMHs), Accountable Care Organizations (ACOs), Embedded Care Management, Transitional Care Management (TCM), and Field Care Management models.
• Process Improvement Specialist with proven effective leadership skills in turning around clinical and non-clinical teams to improve productivity, efficiency, and compliance while increasing job satisfaction and retention. Experience with operationalizing Six Sigma and LEAN Process Improvement techniques to increase efficiency, staff productivity, and improve costs. Focused on delivering patient-centered, clinical programs for national and regional care management operations.
• Demonstrated Effectiveness in Improving Financial Performance by integrating performance improvement with operational efficiencies. Successfully implemented several managed care clinical/ quality improvement pilots with a focus on measurable clinical and financial success goals.
• Licensed Medical and Behavioral Health Clinician dedicated to improving overall patient clinical outcomes (medical and behavioral health), while lowering cost of care. Previous experience in developing Medical-Behavioral Confidential programs in managed care settings.

Areas of Expertise

• Medicaid
• Medicare
• Patient - Centered Medical Home
• Practice Transformation
• Case Management
• Utilization Management
• Disease Management
• Quality Improvement
• Nurse Advice Line
• Chronic Illness Management
• Accreditation and Regulatory Compliance
• Program Development
• Finance & Budgeting
• Operations Management
• Policy Development
• Operational Metrics
• Clinical Pilots

PROFESSIONAL EXPERIENCE

Confidential

Director, Case Management

Responsible for the daily oversight of Clinical and Non-clinical staff who perform Case Management for Medicare and Medicaid lives. Programs include Emergency Department Diversion, Complex Case Management, Palliative Care, and Transitional Care Management.

Confidential

Senior Director, Medical Management Programs

Responsible for the daily oversight of over 100+ Clinical and Non-clinical staff who perform Utilization Management and Case Management for Medicare and Medicaid lives. Also, responsible for clinical and non-clinical oversight of the Multi-chronic Care Management (MCCM) Program, a medical-behavioral integrated care management program for patients with multiple chronic conditions exacerbated by psychological and social factors. Responsible for maintaining contractual requirements and operational initiatives for these care management programs. Though use of Six Sigma and LEAN process improvement techniques, increased staff productivity by 43% and UM turnaround times by 35%.

Confidential

Director of Clinical Operations, Patient-Centered Care Model

Within the Innovations Group of confidential, responsible for the Clinical Operations of the confidential Patient-Centered Care Model Program, focused on collaborating with confidential's on practice transformation techniques, including embedded care management/nurse navigator activities. Actively collaborated with enterprise-wide leaders within UHG focused on Commercial, Medicare, and Medicaid lines of business facilitating medical models and quality initiatives within the enterprise, including Optum Medical and Behavioral Health. Also, under the direction of the Medicare and Retirement Chief Medical Officer, assisted with the oversight of Clinical Care Management Teams and processes related to Medicare and Retirement members. Responsible for the Clinical oversight of the Optum Medical and Behavioral Health Care Management Programs, addressing Medicare and Retirement Compliance issues, SNP Quality Improvement Projects and Process Measures, Delegation Oversight, and Care Management Programs (i.e., Case Management and Disease Management). Lead a national United Health Group Diabetes Quality Improvement Project to improve confidential measures for Medicare members.

Confidential

Medicaid Managed Care Consultant

Assisted Medicaid healthcare organizations with new program implementation and design, including UM Operations, Case Management, and Disease Management programs. Developed expertise in policy and procedure development and revision to comply with accreditation and state contract requirements. Assisted organizations with successful Confidential and confidential Accreditation desktop and on-site review processes.

Confidential

Senior Director, Medicare and Medicaid Case and Disease Management

Oversight of Clinical and Non-clinical Case Management and Disease Management Operations for over 3 million Medicaid and Medicare members and 100+ Clinical and Non-clinical staff. Developed clinical programs to improve confidential and Risk Adjustment measures, utilizing Clinical and Non-clinical member call center staff. Lead the design of the confidential Educational Outreach Program, focused on closing confidential gaps and developed the Transitional Care Management program, demonstrating medical expense reduction on re-admissions.

Confidential

Medicaid Regional Network Director

Healthcare Administrator and Operations Director of the Managed Medicaid Network in the Charlotte, NC metropolitan area. Primary liaison to NC Medicaid Regulators, as one of the largest Medicaid Networks in North Carolina. Primary areas of responsibility included Case and Disease Programs, Pharmacy, and Quality Management Programs. This included development of medical-behavioral quality initiatives to meet state Medicaid requirements.

Confidential

Senior Vice President Consulting

National Healthcare Consultant focusing on Confidential  Accreditation and State and Federal Regulatory Compliance. Assisted national and international health plan and pharmaceutical clients obtain successful national level accreditation for both Confidentials. Areas of expertise included UM, CM, and DM accreditation programs.

Confidential

Senior Vice President of Accreditation

Senior Clinical Executive for this national accreditation organization reporting directly to CEO.

Primary responsibilities included leadership, planning, and operational oversight for accreditation review/audit process of Confidential ’s Clinical and Health Information Technology Accreditation Programs. Responsible for compliance and oversight of accreditation standards for 200+ Confidential -accredited companies.

Confidential

Commercial Operations Behavioral Health Manager

Steady career progression through increasingly responsible positions leading to pinnacle role as Commercial Operations Behavioral Health Manager. Administered daily operations for managed care institution impacting all levels of care for adults, children, and adolescents, including inpatient, outpatient, and residential treatment (RTC) programs. Supervised clinical (RNs and LCSWs) and non-clinical support staff; reported directly to CEO.