Medicare Advantage care organization with 25,000+ employees in TX and FL, generating $1.1B revenue, specializing in UM, CM, and supportive care for health plans, providers, clinics, and home care.Built and led a team of 14 instructors and 2 managers. Developed tailored training for new hires in Utilization Management, Case Management, and Medical Directors. Designed retraining to reinforce regulatory compliance for health plans. Prepared and presented training evaluation reports… Show more Medicare Advantage care organization with 25,000+ employees in TX and FL, generating $1.1B revenue, specializing in UM, CM, and supportive care for health plans, providers, clinics, and home care.Built and led a team of 14 instructors and 2 managers. Developed tailored training for new hires in Utilization Management, Case Management, and Medical Directors. Designed retraining to reinforce regulatory compliance for health plans. Prepared and presented training evaluation reports, oversight of monthly evaluations, and updated training materials as needed.• Led team in high-impact training for new case managers, ensuring smooth transitions. Achieved exceptional post-test scores above 90% and maintained 95% satisfaction rates.• Teamed up with Regulatory Adherence to enhance documentation. Created targeted refresher training, ensuring audit scores hit 95% for Complex Care and Special Needs Plan products, meeting regulatory standards.• Guided managers in audit analysis, refining refresher training focus. Resulted in successful audit scores for Special Needs Plan, Complex Care, and Notice of Medicare Non-coverage.• Boosted NOMNC Audit Scores from 15% to 90% with targeted monthly training. • Partnered with department heads, TruCare vendor, and subject matter experts to train 1000+ employees on significant updates to our electronic documentation system.• Worked closely with department heads and MCG Vendor, trained 3000+ employees to convert from Interqual to MCG criteria, saving millions on contracts. Achieved 90% inter-rater reliability post-training.• Created tailored Coaching Courses for Case Managers and Medical Directors in collaboration with department heads, ensuring effective support for new hires and quality risk adjustment.• Implemented rigorous Kirkpatrick evaluation (Levels 1-4) for NOMNC Letter Process and Complex Case Management courses. Achieved remarkable improvement, raising NOMNC success rate from 15% to 91% post-retraining Show less

New Mexico Medicaid State Run program for United Healthcare Members with 8 employees specializing in prior authorization (PA) and Inpatient Case Management. UHC Community State's revenue is approximately $348.5 billion.• Experience with 3 NM State Audits, FY2012 Audit scores for Policy and Procedures, and onsite file review meet with a 100%. Audits met with 100% again for FY 2013. In 2011 the UM Department for UHC Community and State was the first to pass the National Accreditation of… Show more New Mexico Medicaid State Run program for United Healthcare Members with 8 employees specializing in prior authorization (PA) and Inpatient Case Management. UHC Community State's revenue is approximately $348.5 billion.• Experience with 3 NM State Audits, FY2012 Audit scores for Policy and Procedures, and onsite file review meet with a 100%. Audits met with 100% again for FY 2013. In 2011 the UM Department for UHC Community and State was the first to pass the National Accreditation of Quality Assurance (NCQA).• Tracked UM metrics for PA and inpatient Utilization Management and reported to our State NM Partners. Created and Reported the UM Program Evaluation to the State and monthly Health Quality Utilization Management Committee. • Created process around our new State contract to be implemented in 2014 and collaborated with Optum Behavioral Health Management team to become an integrated program for United Community and the State of NM. • Collaborated with my VP to write our UM Program Description with the new contract language and integrated a Behavioral Health team for UM and Care Management. I also created special operation procedures and policies reflecting our contract, NCQA, Local State, and CMS language. Show less

PHP is a health plan that manages Medicare, Medicaid, and commercial plans with approximately $5.5 billion in revenue.Led a Utilization Management team with 10 nurses and 2 coordinators and was a UM nurse for Skilled Nursing Facilities and Long-term care facilities in NM. • Experience in utilization review for several regional facilities in New Mexico.• Mentored, reviewed, and audited processes of our UR staff. I have carried a case load of 30 members a week that I reviewed using… Show more PHP is a health plan that manages Medicare, Medicaid, and commercial plans with approximately $5.5 billion in revenue.Led a Utilization Management team with 10 nurses and 2 coordinators and was a UM nurse for Skilled Nursing Facilities and Long-term care facilities in NM. • Experience in utilization review for several regional facilities in New Mexico.• Mentored, reviewed, and audited processes of our UR staff. I have carried a case load of 30 members a week that I reviewed using Milliman Care Guidelines now called MCG for continued stay and progress in a Nursing Home.• Collaborated with the team to redesign for complex care coordination for NCQA QI 7 in 2010• Collaborated with Information Services to develop and upgrade our present documentation system (Case Trakker) to comply with NCQA standards.• Educated telephonic nurse care coordination on the nursing care process for NCQA elements, specifically care planning.• Monitored and Mentored care plans for complex coordination for 8-10 Nurse Care Coordinators on a regular basis to ensure compliance for NCQA. Show less