Job Profile SummaryResponsible for supporting clinical regulatory compliance for lines of businesses or a region. Primary duties may include but are not limited to: Leads the coordination and collaboration to ensure compliance with regulatory, accrediting, and Health Plan quality of care and service requirements. Oversees the development of tools that assist in determining exposure to regulatory and accreditation risks and identifies opportunities to manage and mitigate those risks. Collaborates with teams and business management areas to develop metrics for monitoring program objectives, policies, and procedures that support regulatory and accreditation standards compliance. Collects and maintains information related to quality improvement and compliance monitoring activities. Recommends improvements or remediation to risk management, regulatory, and accreditation compliance programs. Supports quality committee activities. Leads department projects and serves as a subject matter expert.

The areas of management responsibility include Case Management (CM), Utilization Management (UM), Clinical Operations, Clinical Systems and Reporting, Clinical Quality Management, Maternal-Child Services, and Medical Cost Management. Participated in State and NCQA audits. Worked to help the quality team to find HEDIS information in clients charts including information on MRP, Women’s health and WCC measures. Oversees Various projects and change management delivered within the scope, schedule and budget given.

Systems and process trainer for Anthem. Systems training includes WMDS, Facets, Care Compass and other internal products. I Also do training on utilizing criteria sets for UM reviewers. Criteria sets include Interqual, MCG, state and internal guide lines. The training that I do includes new hire training, CM and UM theory training, and motivational interviewing. I am a Certified performance consultant and work with managers and other leaders to design and implement trainings for their staff when needed.

Manager of Clinical services and Informatics. Oversaw the UM and CM departments. Oversaw implementations and training of new companies that purchased and utilized the DBMS software as their EMR. Also trained new employees, completed presentations with clients and TPA's demonstrating the value adds of the company. Presented monthly and quarterly reports to management on productivity and benchmark standards for UM and CM.Oversaw URAC accreditation of UM and CM, increased profitability for the company. Expanded business by gaining new clients and increasing customer satifaction of the current client base. Increased employee productivity and morale.

Supervise team of nurses and non clinical staff in the utilization management for a Medicaid company in the state of Indiana. Work to resolve coding and billing issues and developed and implemented a training program for the company. Was a leader and member of various money saving projects.