• Leads Quality and Stars HEDIS, CAHPS, HOS, and Patient Safety strategies for Medicare, Medicaid, and Commercial types of business• Oversees Risk Adjustment coding, audit, education, training, and scribes to ensure compliant billing practices• Collaborates with internal leadership on Annual Wellness Visit completion• Develops Care Coordination criteria, processes for home visits, behavioral health, transitions of care, and high utilizers to reduce readmissions• Establishes education resource materials and tools for Care Coordination, Quality, and Risk Adjustment• Manages vendor oversight of outreach calls to increase gap closures and reduce operating expense• Partners in IPA foundation, monitoring delegated services, and provider engagement• Supports growth initiatives and patient experience/satisfaction• Builds and maintains a cohesive and talented team by establishing clear direction, goals, responsibilities, and performance metrics

• Led and implemented national, cross-market Medicare Stars (HEDIS/CAHPS/HOS/Patient Safety) program across 24 Medicare Advantage plan contracts• Established standard supplemental and non-standard supplemental data process through provider relationships for health plans, yielding a 12% increase in gap closures• Collaborated with VPs of Clinical Affairs and Informatics on Provider tiering Quality metrics and glidepath• Partnered in development of Employee Engagement program for 450+ employees, improved participation by 24%• Managed vendor contracts for data mining and outreach calls to reduce operating expense by 30% • Led health plan Medical Management (Utilization Management, Quality Management, Care Management, Population Health Management) delegation• Established National Quality Utilization and Peer Review Committees with Chief Medical Officer• Managed transportation benefit, attained utilization at $0.98 per member per month• Operationalized daily census for 5 markets with partnership with Data Engineering team• Streamlined Letter of Agreement process with Network and Contracting departments and partnered in development of Network Adequacy annual report• Transformed and implemented automated letter process with vendor, reduced manual processes by 35%• Oversaw federal regulatory deadlines and submissions for participant roster including contracts and fee reduction agreements, capitation, beneficiary notifications, voluntary alignment, and initiatives to support growth of 7%, and CAHPS administration for ACO REACH• Developed mechanisms to capture Heath Equity Data Reporting (HERD), Social Determinants of Health (SDoH) data to maximize health understanding, education tools, and community resources• Supported Board, Health Equity Plan, Quality/Care Management measures, and legal and compliance requirements • Served as company representative quality integration for mergers, acquisitions, and new business ventures

Oversaw National Medical Management Health Plan delegation audits. Developed policies, programs, and strategies for quality improvement. Analyzed metrics to evolve reporting, processes, and training. Streamlined Letter of Agreement process with Network and Contracting departments. Implemented automated letter process with vendor, reduced manual processes by 35%. Coordinated Quality of Care grievances. Engaged team, providers, and patients in CMS five-star quality rating system (HEDIS, HOS, CAHPS).

Developed Utilization Management, Quality Management, Care Management, Population Health Management associated policies and procedures, work plan and evaluation, and National Quality Utilization Committee. Partnered in transportation benefit, attained utilization at $0.98 per member per month. Managed daily operations for the Utilization Management department, overseeing 17 employees; resulted in a 5-day turnaround time for Part C requests and 24 hours for Part B requests. Analyzed metrics in compliance with nationally recognized standards.

Developed and implemented human resource functions, including but not limited to policies and procedures, job descriptions, training, performance management, and team building, across multiple clinic sites, minimizing turnover to 10% year-over-year. Served as company representative for Join Commission surveys and audits for pain management modalities within the surgical suite; attained 96% pass rate. Reduced claims denial rate by 30% in first year through implementation of automated A/R processes. Directed and guided Practice Managers and member of executive team responsible for growth, mergers, acquisitions, fiscal statements and valuation, and reimbursement.

Managed and facilitated NCQA reaccreditation in Utilization Management and Credentialing with 99% pass rate. Operationalized clinical Quality of Care and Peer Review programs. Developed associated policies and procedures, work plan and evaluation, and cross-market Quality Utilization Committee. Member of the Health Plan Delegation team responsible for metric compliance overview to leadership as well as successful coordination of pre- and post- health plan delegation audits for 3 Medicare Advantage plans with a 98% pass rate. Partnered in HEDIS hybrid review in chart collection and gap closures.

Managed human resource functions for a behavioral health organization; over 50 employees/independent contractors. Increased recruitment and of clinical staff by 72% and interns by 112% in 14 months, through implementation of interdepartmental collaboration, independent contractor solicitations, and employee referrals. Created policies, job descriptions, and contracts. Coached leaders and staff to address concerns and problem solved to improve productivity.

Supervised the administration department through employee performance and project management, customer service, and revenue cycle billing. Administered internal patient and personnel file audits, patient satisfaction surveys. Developed quarterly newsletter to external stakeholders and oversaw organization’s social media.

Created credentialing and re-credentialing process for Social Workers, Clinical Professional Counselors, Marriage and Family Therapists, and other clinicians, resulting in Medicare contract, panel growth, and credentialing of 250+ clinicians with Nevada state Medicaid health plans. Conducted training for new hires. Drafted Memorandums Of Understanding and contracts between health plans and medical supervisors. Coordinated health plan audits, monitored, and tested quality improvement processes company-wide.

Established relationships with guests in a hospitality-based in-bound call center. Assisted guests with show and restaurant reservations for 13 properties, through customer service and PCI compliance. Trained and mentored new employees.

Managed procedural responsibilities, including but not limited to check cashing, deposits, withdraws, transfers, cash advances, safe deposit box access, etc. Identified client needs, through account review and information on new products, and directed clients to appropriate representatives. Trained and coached new tellers, handled numerous large money, and business transactions.