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.
• 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)..
• Achieved conversion of level of care from medical inpatient to observation at 27% - 30% trend rate on all products, Medicare, Medicaid and marketplace.

• 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.

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.
• Met thresholds for metrics per MMAI regulatory documentation.
• Maintained consistent compliance with no sanctions; passed EQRO readiness reviews.

• 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.
• 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..
• 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.

• 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.
• 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.

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

Ba, Art

Nursing Diploma, Nursing