Debra M Brophy Mba, Rn-Bc, Ccm Email & Phone Number

United States

Chicagoland

Vice President, Medical Management Oversight and deliverables for integrated care team including hiring, ensuring compliance for adherence to standards, regulatory, InterQual, for Medicaid, Medicare, Dual Needs plan, Long Term Supportive Services rendered in the community setting. Directed and managed 400 + Care management, care coordination and 80 + utilization team members. Provided clinical oversight for all components of program: Utilization management, care management, quality, and compliance metrics. (Promoted from Manager to Director/2013 to Vice President/2017 due to exceptional performance and innovative contributions.)KEY ACHIEVEMENTS● Exceeded savings goal by $20 million in 2018 Goals for Medical Management Department by driving efficiencies through revised utilization and care coordination models.● Met 100 % of 2014 clinical regulatory measures for the Medicare Medicaid Program as related to care coordination practices. ● Handpicked to launch new contractual program Medicare Medicaid Alignment Initiative, CMS Demonstration project. ● Reduced utilization of Neonatal Intensive Care 8%-12% by introducing a collaborative approach to implement clinical strategies (including Discharge Planning, Utilization, Medical director and CHW, and Neonatologist). Reduced utilization resulting in a continuing downward trend of 2.7% as of Sept 2019, by introducing specialized assessments to identify opportunities for interventions, collaborating with PCPs, and developing relationships with Urgent Care Providers.● Achieved conversion of level of care from medical inpatient to observation at 27% - 30% trend rate on all products, Medicare, Medicaid and marketplace. ● Received IlliniCare Health Award for “Exemplary Service and Dedication to The IlliniCare Health Core Values” (2015).

PRESENTATIONS● Presented to Saudi Ministry of Health on behalf of Centene’s RFP Spring 2019. ● Key leader in Illinois State’s 2018 RFP, including written proposal and Oral Presentation to Illinois State - Health and Family Services. ● Delivered presentations on IlliniCare Health plan structure and resources for patient care to hospital system, community, and individual providers.LEADERSHIP● Designed, staffed and implemented clinical, quality and compliance policy and practice of CMS Demonstration project. ● Promoted Patient-Centered Medical Home by facilitating a safe connection between our members, their caregivers, and their PCPs.● Oversaw the initial formation of Integrated Health Home Practice pending state go-live.● Reimagined and deployed resources to decrease care fragmentation resulting in enhanced care understanding and improved quality of care.● Orchestrated the integrated clinical team participation in the case management statewide expansion from 12 counties to 102 counties in the state of Illinois.BEST PRACTICES● Resubmitted Model of Care Formal Centers for Medicare document for Medicare Medicaid Demonstration project Model of Care, describing program, structure and goal outcomes with specialized section specific to State of Illinois questions. ● Implemented a hybrid care management model to include onsite visits (in addition to phone visits) with members and providers for complex interventions, resulting in higher satisfaction and limited staffing loss. ● Oversaw the first Pilot Community Health Worker Program for Centene Corporation; achieving a 95% readmission prevention rate for the pilot group. Collaborated closely with Corporate Team and Manager of CHW Program Pilot Team. ● Oversaw and ensured compliance with new operational mandates for client screenings, assessments, and care plans; established transparent practices for ease of validation.

Westmont, Il

RELATIONSHIP BUILDING● Built collaborative relationships with physician groups and hospitals to bring high-quality care to membership.● Reduced utilization of Neonatal Intensive Care 8%-12% by introducing a collaborative approach to implement clinical strategies (including Discharge Planning, Utilization, Medical director and CHW, and Neonatologist).● Collaborated with Leadership Team to perform cost of care data analysis and identify target population based on clinical condition; created model of a specific clinical approach for care management which resulted in annual cost savings for 3 consecutive years.QUALITY● Met thresholds for metrics per MMAI regulatory documentation.● Maintained consistent compliance with no sanctions; passed EQRO readiness reviews.● Accountable for EQRO document for Readmission Performance Improvement Plan, MMAI QIP (Quality Improvement Plan)● Jointly prepared and owned 2018 NCQA Population Report in close collaboration with Quality Analyst.

● Performed clinical reviews for solid organ transplants approval based on national standards, regulations and individual benefit plan coverage. ● Conducted client assessments and medication reviews, reviewed adherence to treatment plans, identified and addressed gaps in care, and communicated closely with providers to facilitate client-based care management for high cost and complex population of solid organ transplant.● Promoted health self-management efforts for chronic or complex conditions.● Oversaw and reviewed outpatient, home services, and specialty infusions. ● Created monthly report per patient to client describing patient services and costs. ● Promoted from Case Manager Generalist to Case Manager, Transplant due to exceptional skill and performance.

Managed up to 4 care management teams (of 10 each) of specialty RNs who manage cases, monitored contracts and delivered for pre-, during, and after-care services. Staff in Illinois and California. Managed remotely. Reported to directly to VP of Complex Care.● Achieved transplant consumer satisfaction score of 98% for clinical nursing team. ● Managed a Staff Voluntary Turnover at 15 % (lower than corporate target of 18 %). ● Successfully integrated different case management practices from acquisitions and minimize adverse impact on business operations. ● Led core care management model redesign and implementation within national transplant program able to expand interventional model; resulted in increased care management case capacity and cost savings.● Collaborated with Medical Directors, Business Operations, Business Leads to identify solution to provide more high-quality services with current resources.● Led design and implementation new care management specialty program of Congenital Heart Disease to extend Centers Of Excellence to expand neonatal care.● Served as Operational SME for URAC accreditation process.● Served as Care Management Program SME in multiple Six Sigma Black Belt and Green Belt initiatives including kidney specialized care management, and redesign of transplant care management.● Promoted from Case Manager to Supervisor to Manager due to exceptional performance.● Received “Rewarding Results Reward” for contribution toward the success of UnitedHealth Group and Optum Transplant Solutions Business Unit.

Directly managed up to 30 case management and utilization staff for supportive in-patient and out-patient services; managed up to 5 administrative support staff.● Served as case management SME for international self-insured employer with complex cases range from international air transport to transplant care management;coordinated urgent care in US. Created training module for First Health clinical team on how to conduct emergency air ambulance from outside US into US.● Negotiated cost rates for air-ambulance and associated services, saving up to 10%. ● Led and managed clinical call center; tracked metrics; consistently achieved call support objectives. ● Supervisor role ranges cross clinical and non-clinical teams as well as care management/coordination and utilization management.● Known by managers for responsiveness to ad hoc federal CMS audits, resulting in quick resolution.● Promoted from Care Manager to Clinical Supervisor due to exceptional performance.

Master Of Business Administration (M.B.A.)

Ba, Art

Nursing Diploma, Nursing