Description
Summary of Experience More than 16 years of leadership experience in the Managed Care industry including 10 years in healthcare facilities. Extensive experience in developing, expanding, and maintaining provider networks as well as in: Health Care Delivery Systems Network Development Provider Relations Budget Administration Problem Resolution Team Development Trend Analysis/Valued-Based Purchasing Salesforce Data Regulations Merit-Based Incentive Payment System (MIPS) Patient-Centered Medical Home 2016 The Carolinas Center for Medical Excellence Columbia, South Carolina The Carolinas Center for Medical Excellence (CCME) is recognized as a leader in improving health care quality, by providing innovative services and solutions to create healthier communities. Quality Specialist: The Specialists are responsible for interpreting and analyzing provided information to support contract compliance, and maintaining professional working relationships with contract staff, program leaders and health care providers. The duties include assisting with development of methodologies and data collection tools and protocol developing and providing educational materials and programs assisting with identifying and developing systems and processes to enhance contract requirements and providing technical expertise based on assessment and contract requirement. * Identify and share best practices and lessons learned to achieve improvement in healthcare delivery systems, processes, and outcomes. * Monitor and report on progress of tasks and/or phases of the project plan. * Provide direct technical assistance to practice staff in support of their efforts to report Quality appropriate Measures Group and/or PQRS data to CMS. * Provider technical assistance, free-of-charge, to help clinicians and office personnel better understand the new reporting requirements, meet performance goals, and sustain or enhance reimbursement. 2014 to Advicare Health Greenville, South Carolina Sept 2016 A Managed Care Organization supporting both Medicare and Medicaid for South Carolina. Director, Network Management: (2015 - Present) Responsible for the establishment of an effective health care delivery system including Hospitals, Primary Care Physicians, Physician Specialists, ancillary Vendors, and all others, with primary focus on contracting and negotiating contract terms. Responsible for providing accurate, relevant data, and reporting from Quality Department related to Care Gap reports and HEDIS measure to the provider community. * Provided direct supervision and guidance to the managers of contracting and provider data, network development, and provider relations managers. Negotiated financial terms with providers including per diem rates, global rate, and capitation arrangements. * Developed and coordinated provider network expansions into new localities for Medicaid product in accordance with regulatory adequacy guidelines. Compliance Specialist: 2014 - 2015 Responsible for assuring contracts, policies, and procedures adhered to existing regulations. * Analyzed trends affecting service providers to determine or alter an organization's service contracts. Conducted audits appropriate for each department. * Reviewed all gaps in network development recruiting and contracting statewide to open access to care statewide. * Provided oversight and monitoring of Agent/Broker activities to prevent, detect, and correct compliance deficiencies with Advicare Health Policies, federal and state laws, CMS regulations, and other regulatory requirements. * Assured all MMP Marketing events compliant with HPMS uploaded timely and marketing material met all CMS MMP Marketing Material guidelines and uploaded timely for approval. * Promoted to Director, Network Management.
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