Provide leadership and direction for continuous quality improvement (QI) initiatives to improve efficiency, processes and demonstrate improved quality. Provide and analyze reports to identify trends, opportunities and recommend initiatives aimed at improving quality of care and services provided by the organization. Oversee accreditation process, specifically as it pertains to National Committee for Quality Assurance (NCQA) Accreditation and compliance with contractual requirements.• Responsible for overall coordination of company-wide quality assessment and improvement activities.• Oversee and coordinate with Corporate on annual file audits and other quality related initiatives to include those of a contractual nature.• Manage and implement appropriate work tools/processes, reports and audit tools to ensure control of key processes and program characteristics.• Recommend quality improvement opportunities based on findings and participation in developing and implementing solutions to management and the Quality Improvement Committee (QIC) and other committees, as appropriate.• Provide feedback to rectify errors and to prevent further inconsistencies.• Oversee monthly and quarterly reports and data to identify trends, opportunities for improvement and interventions.• Responsible for policies, operating procedures, and aligning goals in compliance with internal and external guidelines.

Oversee, manage and lead all quality improvement functions within the quality improvement program department for three lines of business, which includes HEDIS care gaps, reporting, education and all other quality improvement activities. Providing management support to all direct reports, facilitating communication with other internal staff and departments, and strategizing the daily quality improvement (QI) functions. • Review and analyze reports, records and directives for quality department. • Confer with staff to obtain data such as new projects, status of work in progress, and problems encountered, required for planning work function activities, including prospective and retrospective HEDIS reporting and gap closure. • Manage and lead the Quality Improvement Department insuring all quality improvement measures are taken in a timely manner. • Verify data to be submitted in accordance with government program requirements and ensure compliance with state, federal and certification requirements. • Prepare reports and records on work function activities for management.• Oversee the review and analysis of other internal reports.• Evaluate current procedures and practices for accomplishing the assigned work functions objectives to develop and implement improved procedures and practices and to ensure compliance with required standards.• Manage delegate vendor oversight and corrective action plans as indicated.• Monitor and analyze costs and participate in the preparation of the monthly, quarterly and annual budgets.• Develop, revise and maintain educational resources to educate staff, members and providers on all quality initiatives to ensure members continuity of care remains a constant.

Managed, coordinated and collaborated with providers and customers daily to increase the understanding of Risk Adjustment while utilizing business intelligence tools. Served as a subject matter expert on correct ICD-10-CM coding documentation guidelines to develop, implement and conduct effective training sessions regarding risk adjustment documentation, coding and quality management to promote efficient gap closure activities.• Developed educational resources that educate staff and providers on Risk Adjustment HCC coding practices to ensure customers’ membership risk scores are accurately reflected.• Acted as a subject matter expert, sharing best practices with providers, their support teams and the customer to encourage chronic condition compliancy and quality gap closure.• Served as a subject matter expert and customer advocate for all open issues and drive timely issue resolution for all provider facing tools and solutions.• Conducted RAF analysis to promote targeted chronic condition gap closure for clients.• Primarily support the provider engagement and customer engagement teams with engagement activities including contacting providers via email and phone for outreach, marketing, and engagement campaigns.• Conducted consistent analysis on all provider engagement activities via reporting to internal and external stakeholders while also providing comprehensive reporting on provider engagement activities to each customer.• Developed, conducted, and managed email and fax campaigns to increase awareness and utilization of educational webinars and provider tools.• Managed database of provider engagement contacts, targets, and communications• Followed up on provider feedback submissions to correlate conditions confirmed via claims submissions.• Followed up with providers and support personnel on educational opportunities based on feedback of chronic conditions and quality measures on provider alerts.

Responsible for provider performance management which was tracked by designated provider metrics, inclusive of STARS/QRS gap closure and risk coding accuracy. Working directly with healthcare providers to build relationships, ensure effective education and reporting, and to proactively identify performance improvement opportunities through analysis and discussion with subject matter experts.• Managed and executed applicable provider incentive programs for health plan & necessary reporting.• Assisted in developing and implementing comprehensive, provider - specific programs to increase their HEDIS performance & risk coding accuracy to improve their outcomes.• Provided ongoing strategic recommendations, training and coaching to provider groups on program implementation and barrier resolution.• Acted as lead to pull necessary internal resources together to provide appropriate, effective provider education, coaching and consultation. • Trained medical providers on Stars measures (HEDIS / CAHPS / HOS / med adherence), risk coding submission & accuracy and ABCBS program administration, use of plan tools, reports and systems, etc.• Coordinated and led meetings with provider groups with regular frequency to drive continual process improvement and achieve goals. • Provided reporting to providers, provider groups & health plan leadership on progress of overall program(s) performance.• Facilitated / led monthly or quarterly meetings, including report and material preparation. • Provided suggestions and feedback to health plan on program recommendations/improvement.

(Cigna-HealthSpring was acquired from Humana on Jan 1, 2013)Managed financial reporting and financial analysis on markets line of business. Analyzed medical cost data that drives contracting, marketing, physician engagement and pricing strategies. Provided broad Healthcare & Medical Economic data support to managerial and administrative departments, internal and external whilst remaining Instrumental in managing and nurturing key relationships within the Cigna-HealthSpring network. • Took lead to implement the first STARS, HEDIS and Quality Measures training education for providers in West Arkansas under Cigna-HealthSpring to ensure accurate coding specificity, resulting in an increase of STAR ratings across the region from 2013-2017.• Supported providers and staff in Risk Adjustment and Chronic Condition gap closure activities by engaging and educating providers on correct coding, documentation and quality guidelines.• Experienced in aspects of Coordinated Care Organizations, process improvement, profit and loss management, cost management, provider network building, conflict and issue resolution, contracting, medical claims, payments, and training.• Successfully drove financial and operational activities of extensive interaction with Network Operations and internal staff.• Strong qualifications in strategic, tactical financial planning with equally strong qualifications in Health Plan Operations and business development.• Success in improving medical cost trends by identifying needs and recommending solutions.• Captured significant health care cost reductions through process redesign and performance enhancement.• Provided high-quality, accurate, and timely financial reports to ensure leadership possess appropriate data to execute informed business decisions.

(Acquired by Humana in March 2012 and sold to Cigna-Healthspring on Jan 1, 2013)Served as external Provider Relations Representative for National Medicare Advantage Health Plan. Liaised with departments and appropriate providers in claims payment resolution. Mediated appeals and complaints with Arcadian/Arkansas Community Care departments. Managed provider information to include contracting, directories, summary grids, and analytics.• Dedicated to providing the highest level of network integrity and plan members access to care.• Partnered with delegated PHO systems to provide quality service to all associated providers, while internally scheduling orientation and training. Detailed documentation, compliant credentialing, and creation of provider relationship programs have proven key to establish credibility, satisfaction, and communications.• Successfully analyzed network adequacy and deficiencies with modifications made by targeted network development, contracting and recruiting, rate negotiations, and partners.

Liaised as the Provider Relations Representative bringing Medicare Advantage education, claims support, and general guidance to a network of providers. • Developed and implemented timely implementation of interventions and activities to support the organizations business model and providers. • Successfully handled complex negotiations and relationships, contracted and non-contracted providers; Prioritizing appeals and claims disputes.• Met Plan’s goals by expanding or re-contracting efforts• Maintained Windsor Health Plans Provider directories.

Negotiated contracts and fee schedules between providers and Managed Care Insurance companies. Collected on accounts over 90-120 days past due via calls and claims status. Supervised workflow of 12 associates, filed appeals on incorrect claims and adjustments and posted collection payments provided by Accounts Receivable.• Developed and implemented strategic repositioning, restructuring, product development, fund raising and full operational management for each business unit.• Kept a keen focus on raising standards of operations, risk management, advice and client service and capitalized on technological advantages and the global reach of a new, web-based economy.• Trained new employees in Managed Care rules and regulations for coding services.