Developed long-term strategic plan to transform internal culture related to provider experience, improve provider onboarding, and maintain legacy provider relations to drive business growth.• Built department from scratch; developed and executed roadmap for improved provider end-to-end experience. • Achieved and maintained NPS of 92 for new provider implementations/onboarding. • Built, coached, and developed provider experience team of 10 direct reports. • Cultivated and managed 3000+ relationships with provider practices and health systems, maintaining 100% of legacy providers.• Developed network capabilities by executing over 100 new provider agreements/year. • Inherited and resolved backlog of 1200 provider claims inquiries and reached 24-hour SLA through process improvements: increased team productivity by 15%.• Decreased payment remittance timeframe by 25%.

Review medical records to detemine validity of suit, organize medical records and increase value of case.

Directed operations and quality oversight for Direct-to-Employer (DTE) and Center of Excellence (COE) bundled payment programs covering 2.1 million lives and book of business over $25M. Project management oversight for Medicare value-based care initiatives. • Client clinical relationship lead for Boeing, Chico’s, Comcast, Lowe’s, Kroger, United Airlines, and Walmart, health plans (Anthem, United Health Group), TPAs, and consultants. • Developed and executed strategy to scale COE product portfolio to health plans and aggregators driving 10% sales growth.• Developed and launched a new patient management platform in conjunction with IT.• Consistently achieved HCAHPS greater than the 90th percentile.• Collaborated across the enterprise and with external vendors and payors for primary care clinical transformation to value-based programs, vendor oversight for Epic BPA triggers for HCC risk capture.• In compliance with CARES Act, maximized deployment of telehealth visits for ACO patients. • Understand client benefit programs and interdependencies to facilitate seamless care transitions (Accolade, Quantum, PBMs)• Evaluated clinical and operational implications of contract language and developed appropriate risk mitigation strategies. • Integrated EQ5-D, DASI and PROMIS-10 surveys to monitor baseline and ongoing mental health and activities of daily living scores and set intervention parameters.• Developed and managed relationships with multidisciplinary leaders throughout the enterprise• Authored white paper on travel parameters for cardiac surgery patients.• Consultant/SME for all specialty medical and surgical program development (orthopedic, spine, cardiothoracic, oncology, epilepsy, MS, bariatric, pediatric congenital heart).

Managed daily operations, contract compliance, and medical management for bundled payment programs. Applied project management book of knowledge to advance program capabilities.• Operationalized and scaled $22M National Network cardiac surgery service line. • Client-facing clinical lead for new implementations.• Spearheaded implementation of pediatric cardiac surgery partnership with Boston Children’s Hospital, launching new product line and new reimbursement model.• Decreased client cardiac surgery costs by incorporating telehealth visits.• Managed throughput and transitions of care for specialty care patients locally and nationally.• Developed program-specific patient satisfaction survey in collaboration with PressGaney.

Directed daily operations and process improvements for all medical management functions (utilization case, demand, and population health) for self-insured clients, including travel surgery and transplant Centers of Excellence (COE) programs for Boeing, Lowe’s, and Walmart. • Managed, coached, and developed 16 direct reports, six of whom worked remotely.• Managed $1.5M department budget and productivity.• Decreased new COE patient intake turnaround time from 2 weeks to 3 days.• Achieved URAC reaccreditation. • Monitored, analyzed, and reported on high-cost and zero-dollar claimants.• Collaborated with Medical Director regarding medical management decision-making using URAC, NCCN, MCG • Created and updated department policies and procedures to meet current standards of care.• Reorganized department to improve efficiencies.

Ensured quality of care through medical management, while disrupting healthcare delivery with development and advancement of direct to employer bundled and value-based contracting.• Wrote playbook of best practices for operationalizing/onboarding new clients which became industry standard.• Decreased readmissions from 17% to 0% in first year.• Developed and implemented chronic pain management and spine surgery product lines.• Led Lean project streamlining post-discharge touch points to decrease patient abrasion.• Division liaison to enterprise Care Management department• Project manager for Humana Skilled Nursing project for direct ER to SNF admissions

MedAssurant, Inc., Bowie, MD 2008 - 2011A leading healthcare data analytics technology firm, whose information is impacting clinical and quality outcomes, utilization, and financial performance across the healthcare landscape.Site Review ConsultantPerformed medical record review and abstraction remotely and onsite at care provider offices, clinics, hospitals, and other clinical facilities.• Managed in-depth medical record review and ICD-9 coding for Medicare Risk Adjustment.• Maintained at least 95% accuracy rate.• Maintained HIPAA compliance and confidentiality of all records.• Maintained telephone and electronic contact with schedulers and liaisons in home office.

Physicians for Pulmonary and Critical Care, Mayfield Heights, OH 2005 - 2008A multi-physician practice specializing in pulmonary and critical care medicine.Pulmonary NurseManaged office and assisted with hospital rounding for one pulmonologist.• Improved operational efficiencies in office.• Managed two medical assistants.• Triaged patient calls, refilled medications, scheduled office visits, diagnostics, and procedures.• Monitored patients with lung nodules for ongoing follow-up.• Provided disease and medication education.• Managed relationships with patients / family, office and hospital staff, DME reps, and drug reps.• Performed and documented focused nursing assessments on hospitalized patients.• Identified and documented laboratory, radiologic and diagnostic findings.• Monitored effectiveness of therapeutic interventions.

Hillcrest Hospital, Mayfield Heights, OH 2004 - 2005A full service hospital with 496 beds, Hillcrest is a member of the Cleveland Clinic Health System.Resource NurseStart-up position which served as gatekeeper for medical necessity reviews.• Reviewed clinical information for medical necessity.• Achieved mastery of InterQual criteria and Milliman & Robertson guidelines.• Prevented avoidable days.• Educated case managers on InterQual and Milliman & Robertson guidelines.• Submitted timely electronic and telephonic clinical information to prevent denial of payment.

Advocare, Inc., Warrensville Heights, OH 2002 - 2004A comprehensive provider of Workers’ Compensation, Vocational Rehabilitation, Third Party Administration, and Group Health services.Utilization Review NursePerformed telephone and electronic clinical reviews to determine medical necessity for requested treatments for injured workers.• Developed understanding of the Ohio Bureau of Workers’ Compensation system.• Monitored effectiveness of therapeutic interventions. • Consulted with medical director when necessary. • Worked with ICD-9, HCPCS, and CPT coding.• Transitioned to paperless environment.

Meridia Euclid Hospital, Euclid, OH 1992 - 2002Once a community hospital known for its acute rehabilitation services, this 370-bed hospital is now a member of the Cleveland Clinic Health System.Case ManagerSupported physicians and interdisciplinary team in facilitating patient care with goal of improving clinical outcomes and patient satisfaction; managed cost of care while submitting timely and accurate information to payers. Applied approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays.• Combined utilization review, discharge planning, and quality management role. • Managed concurrent and retrospective chart review for denial of payment.• Collaborated with interdisciplinary team, patients and families, and various community agencies. • Completed psychosocial assessment on specific patient populations.• Chart abstraction for the Cleveland Health Quality Choice project.

Lakeland Community College, Mentor, OH 1990 - 1994A comprehensive two-year college serving the educational needs of Lake county and eastern Cuyahoga county.Clinical InstructorDirect supervision of intermediate and advanced medical-surgical nursing students while they cared for patients in an acute care hospital setting.• Selected appropriate patient assignments for 6 - 7 students.• Developed relationships with hospital staff who interacted with students.• Evaluated students’ pathophysiology diagrams and nursing care plans.• Created pre-and post-clinical conference discussions.• Acted as role model for the delivery of professional nursing care.

Various Employers 1986 - 1995Critical Care Staff Nurse Responsible for utilizing the nursing process to safely, therapeutically and efficiently provide direct patient care.• Direct patient care in ICU, CCU, Neuro-Stepdown.• Handled telemetry at Meridia Euclid Hospital from 1991 to 1995, and Marymount Hospital in Garfield Heights from 1986 to 1991.