Kimberly Croce, Clss Gb Email & Phone Number

Denver, Colorado

In November of 2018, I began CertAvail LLC to continue providing modular MMIS certification services to the State of Indiana from my new home in Denver, Colorado. I have worked with the State of Indiana through my previous jobs and various roles for over 15 years. I am excited to gain the experience of owning my own business and look forward to providing.

Fishers, Indiana, United States

• Worked remotely with the Lawrance Policy Consulting (LPC) team and QSource to support the State of Indiana's External Quality Review (EQR) of their Managed Care Entities (MCEs)
• Performed audit and assisted with planning, management and oversite of the Coverage and Authorization of Services (CAS-04) Code of Federal Regulations (CFR) 2021 compliance standard items for each MCE (Anthem.
• Provided a daily status on the CAS-04 milestones, action items, and issues
• Coordinated with impacted MCEs and vendor staff to complete all required CAS-04 items for the EQR
• Keyed all CAS-04 item findings into the QSource Compliance Assessment Tool and database for each MCE
• Facilitated virtual onsite EQR for CAS-04 and Utilization Management (UM) Denial Files for each MCE and requested any missing documentation

Indiana Government Center South - Indianapolis, IN

• Worked directly with the State of Indiana’s Enterprise Management Systems Project Management Office (EMS PMO) to obtain certification for their newly implemented Medicaid Management Information System (MMIS)
• Assisted with planning, management and oversite of the Medicaid Certification Life Cycle deliverables using the latest Medicaid Enterprise Certification Toolkit (MECT 2.2)
• Tested and maintained the storage site for both PHI and Non-PHI artifacts required for certification
• Provided biweekly status to the State on the Centers for Medicare & Medicaid Services (CMS) certification checklists, action items, milestones, artifacts, risks and issues; as well as monthly status to CMS
• Coordinated with impacted vendors and state staff to complete all required checklists, artifacts and presentations for certification
• Supported the State during their CMS on-site certification visit

Indiana Government Center South - Indianapolis, IN

• Provided Medicaid subject matter expertise to netlogx and the State of Indiana related to the CoreMMIS DDI project
• Performed CoreMMIS meeting facilitation, research, analysis, action item resolution, schedule reviews and defect reporting
• Assisted netlogx and the State of Indiana staff with CoreMMIS implementation planning

Plainfield, IN

• The Lean Six Sigma Program details are as follows:
• Facilitated by a certified Lean Six Sigma Black Belt who trained under a sensei at Toyota
• 36 hours of class room instruction
• 6 months of knowledge provided in a fast paced program
• Required simulated project work
• Team work and collaboration with entire class

Indianapolis, IN

• Indiana Health Coverage Programs (Indiana Medicaid)
• Using the System Life Cycle methodology, defined scope of changes to the business, systems, interfaces, reports, or programs to assess impact, stakeholders, and project plans to meet scheduled milestones for.
• Collaborated with internal / external customers, business / technical teams and impacted stakeholders to elicit requirements, develop designs, create testing strategies / plans, coordinate testing with multiple.
• Provided quality deliverables agreed upon by multiple stakeholders that meet the State of Indiana’s Change Implementation Review Board’s approval
• Performed as Lead Business Analyst on most project assignments, in a client facing role, and committed to meeting deadlines with excellence
• Proven Track Record of Over 40 Successful Project Implementations

Indianapolis, Indiana

• Maintain Master Drug File
• Accurately enter, quality check, and maintain the integrity of the data entered into the internal database for the Medi-Span Master Drug File
• Create data acquisition requests when lacking the necessary information from the drug manufacturer to complete additions/changes to the drug file
• Alert supervisor when a drug/manufacturer has a request that can not be addressed due to legal issues or internal policies.

Indianapolis, Indiana

• Pharmacy Benefit Management Prior Authorizations
• Responsible for reviewing and making determinations on prior authorization requests based on written criteria, the Indiana Administrative Code, and other Pharmacy Benefit Management regulations and guidelines
• Working knowledge of Indiana Health Coverage Programs/Indiana Rational Drug Program, Pharmacy Benefit Management Program, Risk Based Managed Care Program, Restricted Card Program, and ACS Case Management
• Alert potential instances of fraud and abuse to the Surveillance and Utilization Review, and direct provider to the Fraud Hotline when needed
• Utilize First Data Bank for integrity of Drug-Drug, High Dose, and Therapeutic Duplication alerts

Indianapolis, Indiana

• Nursing Agency Contract
• Management and over site of national contract with a large nursing agency
• Liaison to 50 nursing centers and support to over 75 pharmacies
• Supervised a team of 6 associates coordinating first dose medication to expectant mothers
• Set up affiliated pharmacies and negotiate contract terms
• Quality Assurance compliance with JCAHO regulations

Indianapolis, Indiana

• Nursing Agency Contract
• Restructure procedures to enhance productivity to meet demands to growing business
• Rectify escalated customer relations and problem resolution
• IV compounding using aseptic sterile technique in a clean room environment
• Stock emergency drug kits and backup supplies

Kettering, Ohio And Indianapolis, Indiana

• Pharmacy
• Triage all incoming calls
• Computer data entry, process prescriptions, and third party claims
• Inventory, order, and verify in/outbound drug shipments
• Train new technicians
• Set-up and implement new pharmacy locations in Indianapolis, IN

Xenia, Ohio

• Nursing Home
• Assist nursing staff with medical procedures and charting patient daily activities
• Care for patients that require meals, therapy, and assistance with personal hygiene