•Design, develop, and execute corporate strategies, programs, and teams to drive internal and external transformation and adoption.•Act as compliance and privacy consultant for senior executives and ancillary teams, ensuring proper oversight of internal and external needs. Provide guidance surrounding regulatory components at both State and Federal levels.•Led successful URAC reaccreditation survey 3/2024. •Downstream staff accountability of Clinical and Non-Clinical teams from Individual contributors to Director level reports for a total of over 100 accountable reports.•Lead collaboration with cross functional teams to design and implement initiatives aimed at increasing provider, member, and client satisfaction and engagement rates.•Key contributor and stakeholder for enhanced CRM platform contract.•Develop, implement, and oversee large scale cross functional initiatives including programs, policies, and procedures to ensure collaboration reinforced with measurable desired outcomes.•Develop and enhance Case Management programs (specialty MSK, Maternity and Behavioral programs) Disease Management, Population Health, and Casualty services.•Collaborate on RFPs capturing potential client requirements via effective written and verbal communications of company capabilities to support client needs.•Develop and manage financial budgets for current and forecasted growth including administrative and technology resource allocation. •Enhanced decision-making process definition including development and delivery of training materials for staff support. •Trusted advisor to C-Suite through presentation around global strategy opportunities and risk mitigation solutions to promote company and departmental growth.•Lead provider-based engagement initiatives increasing PA experience and efficiencies.

•Key stakeholder for development of 4.6million EMR platform starting from configuration through transition. Led clinical decision making including reporting and process workflows.•Downstream staff accountability of 300+ downstream clinical/nonclinical team members both stateside and offshore.•Defined, developed, implemented and modified clinical based initiatives. •Decreased department spend totals of over 2million with routine review and data analytics of utilization trends and improvement strategy including leading contractual enhancements.•Developed education content, live training, and competency evaluation development.•Vendor Management: On/Offshore teams, cost models, Contracting/SOW, workflow, and productivity oversight. Participation in MBR/QBRs.•Led Successful initial accreditation of UM program from URAC and other State and Federal regulating bodies.•Development of Quality oversight division including staffing, audit tools, calibrations, and compliance reporting in support of regulatory requirements. •RFP development and review process for external vendor parties. •Program Lead for insourcing of MCG Program including Implementation, training for internal and external teams including System Administrator responsibility.•Cross functional support to company teams including Appeals and Grievances, Claims, Network and Contracting, Provider Relations, Clinical Market Performance, Care Coordination/Case Management, Care Navigation, Pharmacy, and Medical Directors.•Development and implementation of high dollar claims review with initial six-month savings identified at 3.6m.•Reviewed, developed, and modified medical policies.•Facilitated project management with implementations in 2018, 2019, 2020. Insourcing 2021-2022.•Developed and facilitated provider experience with education and communications to regarding in the use of electronic portal submissions increasing from <10% to >56% in 9months.

• Development and implementation of Standards of Practice for the Oncology and Genetic Testing Denials and Appeals Specialists as it relates to Medicare, Medicaid, Commercial Payors, Managed Care and Third-Party Review Organizations.• Manages and prioritizes timely review, investigation and response to Oncology and Genetic Testing Denials and the required actions for appeals within contractual timeframes.• Conducts ongoing education of Oncology and Genetic Denials and Appeals Specialists as it relates to analysis of adverse determinations, timely review and response to payor denials, and maintenance of department metrics.• Coordinates and collaborates with Content Experts cross functionally as needed to obtain necessary documentation to support oncology and genetic appeals and implement prevention.• Assist with the development, maintenance, and management of cases utilizing an internal tracking tool for the distribution of reports.• Identification, monitoring and presentation of monthly denial performance trends utilizing case studies resulting in recommendations for Process Improvements to the Revenue Cycle Management Team.• Identify potential risk for loss reimbursement related to medical policies and prior authorization requirements, escalation of potential issues to clinical stakeholders.• Participation in company-wide strategy meetings as needed.

*Oversight of daily operational needs related to Clinical Programs including in person and virtual communications with internal teams and vendor managed book of business.*Led insourcing of MCG Program including Implementation, training for internal and external teams including System Administrator responsibility.*Assist in Implementation of new EMR program including testing, training for internal and external teams, and workflow development.*Cross functional support to company teams including: Appeals and Grievances, Claims, Provider Relations, Clinical Market Performance, Care Coordination/Case Management, Care Navigation, Pharmacy, and Medical Directors. *experienced care across the continuum including but not limited to: medical, surgical, prior authorizations, mental health. *Collaborate with Medical Directors for Policy updates, development, and implementation.*Population Health representation at internal and external meetings.*Identified/Implemented routine monthly meetings to provide education for internal Case Management and Clinical Market Performance teams for education or updates on internal programs.*Project Management history with vendor implementations in 2018, 2019, 2020.*Supervisory background including partnering with internal Human Resources teams and external agencies for job description listings, interviewing, employee coaching and ongoing administrative opportunities.*Facilitate education and communications to partners regarding operational needs including education in the use of electronic portal submissions.*Regulatory knowledge surrounding Medicare (CMS) and Individual & Family Plan needs including understanding of state regulations and impact surrounding turn around times and other state mandated benefit requirements. Includes Audit development and management leading to improved process development and change.

Childbirth (Parent) Educator – May 2016- Current• Parent Educator specializing in Childbirth Preparation.• Provide tours of The Mother Baby Center incorporating information regarding the labor experience within the Allina Health System. Labor and Delivery RN / Preceptor - August 2013- May 2016• 11 labor beds / 3 OR unit /6 bed outpatient triage / 4 bed high risk antepartum unit.• Experience in high risk laboring & post partum mothers: HELLP Syndrome, Pre-Eclampsia, Magnesium Sulfate infusions OR circulator, PACU recovery and Immediate post delivery care• Outpatient Labor Triage including speculum exams. Inpatient pre-op C/S admissions.• Preceptor to staff nurses and students in areas of patient care, policies, and procedures.• Experience in blood administration, PCA’s, and Epidurals/Intrathecal assistance, and PIV placement and lab draws.

RN Nurse Coordinator/Appeals Reviewer/Claims Reviewer• Liason for team/upper management during absence of supervisors.• Perform inpatient and outpatient, pre-admission, concurrent review and decision support based on medical necessity, appropriateness of treatment setting and length of stay utilizing criteria, community standards, and professional medical judgement; including complex conditions such as transplants, ICU/NICU stays, clinical trials, and transition of care.• Comprehensive appeal review with direct support to Medical Director with compilation of preservice appeal investigations (overturns completed independently as appropriate) and recommendations for determinations outside of criteria for medical necessity.• Process pre and post service appeals with outside reviewers as needed.• Review Pharmaceutical requests for most cost effective and efficient services to benefit the member and company while utilizing internal criteria and FDA labels.• Document timely and concisely applying accurate benefit information to each situation while maintaining regulatory compliance for both state and regulatory departments. • Identify High dollar, high risk cases and intervene with appropriate referrals. • Perform utilization reviews for appeals and extended hour nursing with coordination of peer reviews.• Make recommendations for flexing or extending benefits to prevent the possibility of using more costly services with equivalent outcomes.*Coordinated appeals with Pharmacy Benefit Managers (PBM) for in depth medical and benefit review. Recommendations for flexing and extending benefit coverage.

•3 bed Pre Operative / 2 bed Post Operative Ambulatory Surgery Center. •Assess physical, psychological, spiritual, cultural, educational and developmental dimensions of the patient from pre-op phone call through patient discharge, and provides written documentation of these findings. Peripheral IV placement.•Monitor patients utilizing nursing judgment and knowledge of equipment based on policies and procedures from patient admission to dismissal.•Collaborates with other disciplines and departments to maximize patient outcomes and smooth flow of the perioperative experience.

•9 bed Labor & Delivery unit/ 8 bed Post-partum unit averaging 1500 deliveries/year and Outpatient Labor Triage.•Charge Nurse: post partum - Managed adequate staffing levels, scheduling, assignments, communication between ancillary departments, and patient advocate, in addition to managing a patient assignment.•Level 2 NICU and Newborn Nursery Care including: Bili lights and blood draws.•Experience in high risk laboring and post partum mothers: HELLP Syndrome, Pre-Eclampsia, Magnesium Sulfate infusions, experience in blood administration, PCA’s, and Epidurals/Intrathecal assistance. and PIV initiation.•Teaching from birth – discharge including: newborn cares & breastfeeding support (85% initiation of primary breastfeeding). •In-patient/c-section admissions with fetal heart tones and/or continuous monitoring. Immediate post op and post delivery care management. •Preceptor to Staff nurses and nursing assistants in areas of patient care, policies, and procedures.