Sharon Stultz Email & Phone Number

In this role, I ensure full compliance with CMS, state, and federal regulations for Blue Cross Blue Shield by performing meticulous quality reviews on both denial and approval letters. Every day, I manage the review of 15-20 batches of denial letters or 6-8 mixed batches, each ranging from 500 to 3,000 pages. My focus is on spotting inconsistencies, correcting errors missed by the initial utilization review, and identifying trends to enhance the clarity and accuracy of health plan communications.I strengthen our compliance standards by highlighting documentation gaps, making sure that decisions align with regulatory criteria, and proactively reducing potential liability.By escalating unresolved issues, I help minimize CMS, URAC, and NCQA risks, improving our overall compliance and safeguarding the integrity of our processes.

During my time as Senior Manager, I played a key role in driving operational transparency and accountability. I created tailored reports to provide critical insights into our compliance and customer engagement efforts, while proactively eliminating CMS STAR-related risks. By closely collaborating with leadership, I led initiatives for continuous improvement, maximizing our regulatory adherence.I achieved a 4.5 out of 5 CMS STAR rating by reengineering workflows, implementing performance tools, and optimizing staff roles.I introduced a data-driven workflow that streamlined procedures, slashed operational costs, and boosted customer satisfaction.I successfully secured NCQA accreditation by conducting a thorough gap analysis, optimizing processes, and implementing targeted improvements.I led my team to a flawless CMS audit with zero findings, thanks to strict adherence to processes, comprehensive staff training, and robust controls.I cultivated team growth, promoting high-potential employees to leadership roles and creating a culture of accountability and recognition.

As Project Manager, I led case management programs for high-risk patient groups, including maternity, NICU, and oncology cases. Collaborating with cross-functional teams, I continuously improved operational procedures and maintained CMS compliance and audit readiness for our AZ Medicare Advantage program.I improved our nurse-to-member ratio from 1:55K to 1:95K, achieving this by eliminating inefficiencies without increasing operational costs.By using Six Sigma methodology, I prevented the need for hiring 200 additional staff, boosting workforce efficiency by 70%.I developed a resource allocation tool that scaled from 3 to 20 programs, significantly improving cross-functional collaboration across departments.I drove provider collaboration programs to support critical, high-risk populations, enhancing patient outcomes.I standardized communication for regulatory compliance, ensuring medical policy adherence and clear, consistent referrals to the Medical Director.

As Manager of Complex and Catastrophic Case Management, I focused on enhancing patient care and reducing bed days. I established multidisciplinary teams to remove case management barriers and foster collaboration, while preparing for client audits and URAC surveys.I reduced hospitalizations for chronic cases by coordinating case discussions with Medical Directors, targeting patients with high ER and hospitalization usage.I standardized over 150 SOPs across programs to ensure consistent case management practices in line with URAC and NCQA accreditation.I successfully retained 15 team members by reallocating roles after a line of business closed, supporting team stability.I enhanced program outcomes by integrating social determinants of health, improving support for high-risk patients.

As a Project Manager, I developed Cigna’s ACA case management program from the ground up, setting up tools, processes, and reports to align with CMS requirements. I also created training programs to ensure smooth implementation across teams.I cut inappropriate case referrals by 45% with a triage case management tool.I eliminated incorrect Medical Director reviews by designing a tool that auto-assigned cases based on state licensure, streamlining the review process.I gained recognition for improving customer outcomes and operational efficiency, bridging gaps in discharge planning and enhancing care transitions.