Kelli Capps, RN

405-***-****

acthgh@r.postjobfree.com

Career Summary

Fourteen years of experience, including ten years of health care management involving Medicaid and commercial network management, product management and client support management.

Healthcare Management Systems, Holdings April 2013-Present

Director of Appeals – September 2015-present

-Oversight of all complex appeals for Commercial, Medicaid and Medicare contracts.

-Contracted and credentialed physicians and clinical consultants based on individual contract requirements.

- Managed staff and physicians related to complex appeals (ALJ) for CMS/Medicaid and Commercial lines of business

-Managed remote staff of 17 direct reports and 40 indirect reports working in various parts of the US.

-Developed appeal reports to identify volumes, productivity, win rates, by contract and/or clinician, etc.

-Worked with directors and VPs in various areas of organization to discuss how we appeals team could better meet the Clients expectations while managing to what was contractually required. -Met with SME to build appeal reports for each client as well as a dashboard that could be provided to executive leadership on an ad hoc basis.

Director, Clinical Operations- April 2013 to September 2015

-Operationally accountable for the Recovery Audit Compliance Division

-Responsible for meeting contract deliverables for 32 State Medicaid agencies totaling $385 million in

annual revenue

-Successfully implemented 12 contracts on newly developed platform prior to December 31, 2013

-Aligned budgets to meet financial projections

-Trained, developed and provided oversight of 105 administrative and remote clinical staff nationwide

-Developed and maintained strong business and clinical relationships with State officials, facilities and providers

for each contract

APS Healthcare, Inc June 2006-March 2013

Director of Clinical Programs- October 2009 to March 2013

-Operational lead and point of accountability for the Oklahoma Service Center of APS Healthcare.

-Responsible for maintaining operations and meeting contract deliverables for five programs totaling more than

$20 million in annual revenue

-Aligned 80+ remote and local clinical and support staff and daily operational processes to meet needs of programs

-Aligned budgets to meet corporate financial expectations

-Provided operational leadership, modeling and coaching to Service Center staff

-Successfully lead URAC accreditation and reaccreditation efforts for UM, CM and DM

-Trained, developed and provided oversight of clinicians supporting Colorado Health Care Policy and Financing Medicaid Program, Oklahoma State Education and Employees Group Insurance Board, Federal Employees

Benefit of Montana, and Montana Associations County Health Care Trust, Nevada Public Employees Benefit Plan.

-Facilitated operational staff meeting

-Participated in client operational meetings

-Developed and maintained strong business and clinical relationships with state officials/staff, facilities and providers

in a manner that enhanced the value of APS Healthcare.

-Sole resource for direct reports including but not limited to: protocols, staffing issues, trouble-shooting, conflict resolution (internal and external), workloads/flows, production and personnel issues.

Clinical Manager-APS Healthcare June 2008-September 2009

Implemented $9.7 million contract for Oklahoma State and Education Employees Group Insurance

Board (OSEEGIB)

-Complied with program requirements of contracted clinical services including oversight of care management

functions, quality initiatives and delivery of evidence-based practices.

-Trained, developed and provided oversight of 42 clinical and non-clinical APS staff supporting OSEEGIB contract.

-Interacted with APS Medical Director, physician advisors, providers and members.

-Resource for direct reports including but not limited to: protocols, staffing issues, troubleshooting, conflict

resolution (internal and external), workloads/flows, productivity and personnel issues.

-Identified and resolved various member/provider issues.

-Facilitated oversight of quality improvement for OSEEGIB contract.

-Managed to departmental budget

-Developed and maintained strong business and clinical relationships with state officials/staff, facilities and providers

in a manner that enhanced the value of APS Healthcare.

Inpatient Behavioral Health Manager-APS Healthcare- June 2006 to June 2008

Managed Oklahoma Medicaid Behavioral Health Utilization Management Department

-Assisted with management of daily operations in absence of Executive Director.

-Responsible for all human resource issues for OKC office.

-Monitored maintenance and compliance with all the rules and regulations as established by Federal and State

governing agencies.

-Assisted with Inspections of Care audits for Oklahoma Medicaid Program.

Director of Nursing-High Pointe Healthcare, LLC- June 2004 to March 2005

Directed, supervised, evaluated and counseled nursing staff and ensured quality patient care is provided.

-Ensured adequate staffing was maintained in order to achieve department's function and purpose

-Maintained administrative continuity in absence of CEO/COO.

-Maintained compliance with all the rules and regulations as established by external governing agencies.

-Developed standards of care and performance and implemented mechanisms for ongoing evaluation and

improvement of performance standards.

-Adhered to established departmental operations and salary budgets.

Caremark Rx, Inc- September 2003 to April 2004

Patient Educator (Travel Nurse)-

Responsible for educating newly diagnosed patients on managing and controlling their disease process.

-Management and maintenance of patient files with an emphasis on confidentiality.

-Monitoring and supervision of medical receptionists for quality assurance

-Accepting emergency calls after hours as required.

OU Medical Center- January 2002 to September 2003

Staff RN May 2002-September 2003

Emergency Department - -Assumed responsibility for an assigned group of patients

-Documented patient responses to nursing interventions and prescribed treatment notes

-Assisted physician in the examination of patients and in performing minor diagnostic procedures and

treatment.

-Obtained and monitored physiological data of patients, observed the physiological manifestations and

intervened when necessary.

-Administered medications as prescribed

-Informed patient and family of hospital procedures

-Made referrals regarding patient care needs to appropriate personnel

-Shared care plan with patient and family while in the hospital and at time of discharge.

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R.N. Internship January 2002 to May 2002

Surgical Trauma Intensive Care Unit -

University Hospital

-Total care of 1-3 acute patients.

-Assigned to preceptor who monitored progress in caring for patients using a holistic approach.

EDUCATION:

Lean Six Sigma Greenbelt training

Health Data Insights, Las, Vegas, NV

January 2016

AS in Nursing

Oklahoma City Community College- Oklahoma City, OK

2002

RN License # 77134, expiration 12/31/2016

MA in Communications

University of Texas at San Antonio - San Antonio, TX

1994

BA in Public Relations

University of California at San Diego - San Diego, CA

1991

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