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 support on future projects.

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, CareSource, MDwise, and MHS)• 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 • Input final determinations for scoring into designated tools post EQR virtual onsite meetings • Informed the MCEs and Indiana State's Family & Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) of the CAS-04 Strengths, Suggestions, and Areas of Non-Compliance (AON) • Contributed CAS-04 and UM Denial File findings for the MCE 2021 Compliance Assessment and AON Reports

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• Knowledge check to pass the course• Example of work to pass the course

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 implementations• Collaborated with internal / external customers, business / technical teams and impacted stakeholders to elicit requirements, develop designs, create testing strategies / plans, coordinate testing with multiple entities, and consult or write member and provider communications in the form of Banners, Bulletins, or Presentations• 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 • Integral to the success of project implementations such as: • Hoosier Care Connect • Revised 1500 Claim Form • ICD-10 • Right Choices • Care Select • Medicaid Rehabilitation Option (MRO) • SmartPA • Hoosier Healthwise Open Enrollment • Prior Authorization Letters • Integrated Test Facility • Presumptive Eligibility for Pregnant Women • Collaborated with multiple stakeholders such as; Advantage Health Solutions, Anthem, Community Mental Health Centers, Division of Mental Health and Addiction , Family and Social Services Administration, Managed Health Services (MHS), MAXIMUS, MDwise, netlogx, Office of Medicaid Policy and Planning, Optum, OptumRx, SVC, Inc. and others to develop strategic solutions for 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