Project Director Assurance Manager

Elizabeth McConnell

Reynoldsburg, Ohio *****

Phone: 614-***-****

Email: ado2xa@r.postjobfree.com

Career Summary

A proven, hardworking leader that sets the bar with a drive for results and with utmost compassion for every challenge presented. With an eye for detail and a strong ability to communicate and effect a common vision I have spent my career mentoring and motivating people, helping those I serve and constantly finding and capitalizing upon continuous improvement. Thirty plus years’ experience in the Medicare/ Medicaid field; nearly two years in Workforce Analytics.

PROFESSIONAL EXPERIENCE

Torii Behavioral Health (Acute Hospital start up) January 2021 to present

Director of Compliance, HIPAA, Quality and Risk

Developed and implemented policy and procedures for the acute behavioral hospital

Successfully developed and implemented corrective actions to an existing Plan of Corrections from OhioHMAS

Successfully developed and implemented corrective actions to an existing Plan of Corrections from The Joint Commission

Performed quality reviews on each caseload to ensure timeliness standards were being met and presented findings in the daily Leadership meeting

Submitted daily, weekly, and monthly reports to the Division Compliance Manager.

Partnered with the CEO on a daily basis to ensure all of the regulatory standards were interpreted and implemented correctly.

Investigated any incident involving the staff and patient

ResCare Community Living Columbus, Ohio July 2019 - January 2021

Quality Assurance Manager and MUI Investigator

Managed and updated internal tracking systems while reviewing case files to ensure compliance with contractual agreements

Assisted with the development, implementation and enforcement of quality assurance plans

Conducted Company Quality Measurement Tool standard quarterly reviews to ensure standard operating procedures and services were being effectively delivered

Recommended corrective actions; implemented corrective action plans, regarding overall project success

Followed and implemented applicable federal, state and local laws and regulations

Demonstrated computer skills, able to use various software programs for correspondence, reports, statistical compilation and analysis, and database access

Established and maintained effective working relationships with, and among, all personnel and County officials.

Was on call 24/7 365

Maintained the confidentiality of all information housed in the division

MAXIMUS Federal Services, Pittsford NY (Remote) March 2018 to March 2019

Project Director Part C and Medicare Managed Care

Responsible for setting strategy and action plans to meet costs, schedule, and quality requirements of the Medicare QIC Part C Managed Care and PACE program.

Oversees all contract administrative functions including budget, financial controls, and contract compliance.

Responsible for the reduction of the reopening workload backlog that occurred from October 2017 through March 2018. Through planning and reallocating staff, was able report reopening compliance by August 2018.

Worked hand in hand with the health plans to ensure their appeal cases were adjudicated correctly.

Successfully submitted the STARS reports to send to CMS.

ResCare Workforce Services, Columbus, Ohio March 2017 to March 2018

Managed ten employees in accordance with company and contract requirements ensuring compliance with Center/ResCare policies and procedures.

Created various reports to analyze information to determine performance against contract and goals.

Developed strategic plans/quality management and provided staff training to assure all goals were met.

Provided assistance to the Project Director in managing the project monitoring and evaluation system, including project indicators and outputs to develop and promote appropriate evaluation strategies for center activities

Responded to inquiries by Funding Source and or ResCare as required and understand training and needs assessment by providing leadership in developing and implementing solutions for various challenges.

Interpreted and applied regulations and policies and ensured consistency and compliance with governing laws and regulations.

Investigated and developed/recommended solutions to inquiries, problems and issues with the seven Partnering Agencies.

Manager Medicare Managed Care Appeals and Grievances and Quality-

BCBSNC Winston Salem, NC June 2013-Dec 2016

Facilitated and adhered to processing timeliness to ensure compliance of CMS mandates and initiatives; while ensuring accurate, updated operating procedures and systems.

Managed processes to complete job descriptions/expectations and training standards for the disciplines such as Appeals Specialists, Department Auditors, Compliance Consultant, and Department trainer.

Managed team resulting in a Managed Care membership average of 220,000 with an A/G volume average of 6052 between 2014 and early 2015, exceeding past BCBSNC levels. Oversaw training, tracking, monitoring, and analyzing key productivity and quality measures, implement corrective actions and improvement plans as needed.

Provided management of the Prescription Drug Plan's processing budget to ensure high quality, cost-effective results and conformance to annual budget, applying the same processing and compliance expectation as applied to the A&G Program and was managed successfully.

Manager Medicare Patient Financial Services-Mt Carmel Health Systems, Columbus, Ohio 2011-2013

Managed, Patient Accounting; Medicare/Medicare HMO (eleven direct reports) and was directly responsible for the planning, organizing, staffing, managing & coordinating for billing Medicare and collecting on Medicare & Medicare HMO accounts; and for the timely collection of insurance collection for these payers.

The following goals were set and achieved by the department; collect 97% or greater of the net revenue for assigned parts of the receivable, to achieve monthly cash goal for assigned part of the receivable, to maintain the aging at greater than 90 days to 15% or less of the receivable, analyze denial/rejection trends and implement strategic plan to reduce high volume preventable errors.

Ensured the staff monitored patient account balances, insurance balances, and patient follow-up schedules; by identifying, logging, and resolving payer issues and provide upward communication of issues, status, and resolution of payer issues. This included Medicare, Medicare Managed Care accounts, and Indirect Medical Education (IME).

Maintained access to billing for Section 1011, ensured appropriate and timely identification of patients in order to bill within the allowed time frame, monitored Hospice patients who chose to revoke the Hospice Benefit for care provided during the Hospitalization and bill the claims to Medicare, and ensured the identification and accurate billing for patients that come to Mt. Carmel from a Skilled Nursing Facility (SNF) to prevent a Medicare claim reject because of a SNF stay.

Manager of Medicare Appeals and MSP Correspondence Palmetto GBA Columbus, Ohio 2005-2011

Responsible for a cross-functional team of 28 specialists in disciplines such as Appeals Specialists, MSP Correspondence Specialists, Qualified Independent Contractor (QIC) Coordination Specialists, and Operations Analysts for a $12,000,000+ annual appeals budget and a MSP budget of over $5,000,000. Successfully ensured compliance with all CMS requirements, facilitated and improved appeals processing timeliness, which resulted in a reduction in the average number of days to process from 48 to 35 to meet the CMS timeliness metrics, by implementing CMS mandates, change orders, critical tasks and initiatives, while ensuring accurate, updated operating procedures and systems.

Prioritized and monitored workflow/workload of change orders and task orders while managing the Part B Appeals and MSP correspondence processing budget to ensure high quality, cost-effective results and conformance to annual budget. Participated in the successful completion of obtaining ISO 9000 certification and maintaining the ISO certification for Ohio/WV Part B Appeals and MSP. Oversaw training, tracking, monitoring, and analyzing key productivity and quality measures for the department.

Implemented corrective actions and improvement plans when warranted, by developing and providing feedback as necessary for both the individuals in the department and the department itself.

Supervisor Medicare Call Center- Palmetto GBA Columbus, Ohio 2002-2005

Managed and developed a staff of 55 Customer Service Representatives (CSRs). Ensured compliance with all CMS contractual requirements, e.g., CPE requirements. CMS mandates, change orders, critical tasks, and initiatives by implementing timely and accurately while ensuring accurate, updated job procedures, and provided oversight for Call Center training curriculum revision.

Ensured ISO certification for Ohio/WV Part B Provider Call Center team was maintained by auditing and refresher training. It was imperative to develop and motivate staff to achieve individual and department wide goals and benchmarks by educating them on what these goals and benchmarks were and the expectations. By Leveraging in-depth knowledge of the Medicare system to analyze key productivity and quality metrics, the manager could increase operational efficiency on all levels.

EDUCATION AND CERTIFICATIONS

Masters of Health Administration and Management- Colorado State Global Campus February 2018

Masters of Business Administration – Franklin University, Columbus, Ohio May 2012

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