Led team of Case Managers, analytics professionals, and educators with an annual operating and information systems budget of $13,000,000. Directed planning and monitoring of processes and systems to ensure quality of service and achievement of business objectives through integrated care management services. Optimized ability to prepare for and respond to key business opportunities, and led operations management initiatives in order to position department related to risk-sharing agreements, shared savings plans, self-funded obligations, and divisions of financial responsibility (DOFR) in managed care contracting.Partnered with vice presidents of revenue cycle, managed care, and compliance to create and monitor standardized workflows that decreased account receivables and payer denials, assured compliance with governmental billing requirements and managed care contractual obligations, and leveraged economies of scale by centralizing functions. Established and oversaw reporting and analysis of key outcomes such as readmission reduction, LOS goals, Medicare recovery audit contractor denials, QIO and CMS audits, etc. Designed analytics and communicated findings to key stakeholders facilitating collaborations to improve performance across departments, affiliates and entities.

Expanded standard case management UM work processes from 7 acute care hospitals to 24Designed standardization, auditing and feedback which improved UM accuracy from 67% to 92% enterprise wideCollaborated with revenue cycle leaders to re-engineer, test, and audit operations policies and procedures improving acute care business objectives in authorizations and denials managementDirected process improvement which increased successful clinical denial overturn rate at the first level to 73% and 65% at the second appeal level by aligning contract terms with comprehensive clinical appealsCentralized all auditing and communication of acute utilization management to external payersEstablished pre-bill MCFFS short stay patient status review with two day turn around and 100% accuracy on recent external auditCo-led design teams building registry-based identification of high risk populations with associated interventions and reporting in EPIC Healthy Planet for telephonic disease management program and complex case management programsEstablished methodology and reporting for length of stay benchmarks and goals across organization

Formed and led regional UM regulatory compliance teams and provided ongoing consultation services to acute care facilities regarding patient throughput, readmission reduction, denials reduction, and other case management related outcomes. Developed regional CM reporting and analysis, including processes and metrics, MIDAS workflow standardization, and support resulting in measurable and actionable process oversight. Incorporated quality initiatives resulting in innovative and cost-effective programs contributing to positive patient and financial outcomes. Researched and provided analysis of similar healthcare markets in order to compare/contrast and promote adoption of best practices.Directed medical management team and physician’s alliance authorizations and referrals and regulatory compliance team, resulting in more collaborative and effective partnership, and more efficient patient care referral processes. Built standard workflows, engaged employees, and increased performance outcomes and quality of care in conjunction with acute care and disease management colleagues. Oversaw SHSSR Sutter Select self-funded health plan-strategic direction and medical management operational leadership. Established and published department metrics, used daily engagement systems, and celebrated exceeding expectations for staff and market performance.Restructured medical management RN CM team adding extender model significantly reducing department FTE costs by 27% while improving authorization turn-around time from 12 days to three in capitation environment of 160,000 management care lives. Regulated case management workflow for seven hospitals including all measurement systems, internal auditing, and decision support.Implemented MIDAS+ system, InterQual, and CERMe in region’s acute care hospitalsLed implementation of ECIN post hospital referral software implementation for post-acute placement

Leadership and project management for teams ensuring performance improvement with measurable, impactful, cost effective outcomes consistent with provider and patient care goals. Identified gaps in quality performance and process compliance. Presented project plans, gaining senior level support and resources for change implementation. Oversaw provider funding initiatives that supported regional priorities including payer and provider relationship management, contract feedback and review and reporting.

Responsible for utilization management inpatient and outpatient for sub-capitated managed mental health care organization. Patient membership 60,000. Also responsible for mental health utilization reporting for medical groups, IPA and hospitals.

Provided direct patient care to adults and adolescents on inpatient psychiatric units. Staffed triage and admissions assessment and emergency call center. County emergency room 5150 designate. Member of Critical Incident Stress Debriefing team.