Quality Manager
Resume:
Patricia (Trish) Hatfield Winkler
**** ********* *****, ******** *****
832-***-**** (cell)
******************@*****.***
Professional Summary
I have 20+ years’ experience working in Managed Care. The last 17 years of my career have been focused on managing Clinical Quality Management and enhancing organizational performance. I have experience managing HEDIS, NCQA accreditations and URAC accreditations.
Work Experience:
Teladoc Inc.
11-2015 to 7-2017 Director, Clinical Quality Management
Developed and executed the process to update and enhance the quality assurance program, including related plans, programs, processes and procedures.
Created policies and procedures for physician quality review, member utilization reviews, member and provider complaints and grievances.
Responded to various client and account inquiries related to the provider and clinical quality areas.
Generated departmental performance statistics, and prepared the organization for URAC accreditation.
Effectively controlled the release of proprietary and confidential information.
CHRISTUS Health Plan
09/2014-10/2015 Director of Quality Management
Implemented and maintained contractual specifications related to quality,
Developed and maintained annual CQI Plan and indicators for monitoring compliance
Supervised the CQI and Credentialing Teams to ensure URAC and NCQA standards were met.
Promotion of continuous quality improvement activities within the entire organization.
Value Options
12/2013-09/2014 Director of Quality Management
Managed a startup account by organizing and facilitating multi-discipline workgroups in systematic approach to problem solving.
Conducted Quality Improvement Activities and studies on specific utilization and quality issues identified as consistently requiring opportunities for improvement.
Conducted oversight audits to sub-delegated organizations for utilization management, credentialing, customer service activities and claims processing.
Manage all operational issues for the site and host weekly meeting with the client to ensure all goals and performance goals were being met.
Magellan Health Services, Corporate
11/2012-12/2013 National Quality Director
Lead and coordinated national quality communications and provided leadership role for enterprise-wide quality program.
Directed national quality projects including: Writing proposal responses, customer presentations, process improvement activities, accreditation support, development of quality documents and communication materials, quality studies, quality auditing, and provided support for quality committees, product development and new business implementations.
Directed CQI and Six Sigma projects providing support to units across the enterprise through materials, consultation and project management and measurement assistance leading to operational effectiveness and efficiencies.
Supported national projects including new business implementations, HEDIS planning and interventions, outcomes management, quality auditing and accreditation and data analysis.
AMERIGROUP Corporation (MCO), Houston, Texas
05/2008- 11/2012 Associate Vice President Quality Management
Provided leadership in the development, coordination, implementation, and evaluation of the continuous quality improvement initiatives throughout the company in the areas of quality of care, quality of service, and provider/member satisfaction.
Provided direction, leadership, and education for compliance with NCQA standards to achieve and maintain NCQA accreditation.
Supported coordination of the quality management process program across the company by sharing replicable technology, benchmarking, and best practices.
Oversaw complaint and appeal process.
Provided leadership for and supervised the member/provider satisfaction survey process.
Managed the Health Employer Data Information Sets (HEDIS) reporting and provides leadership to the development and realization of action plans to achieve target improvement goals.
Supported the health plans External Quality Review Organization (EQRO) state audit processes.
Provided supervision and leadership to Quality Management representation in new business activities (RFP responses, new market/product development, and state contract changes etc.).
United Health Group-DBA EVERCARE (MCO), Houston, Texas
01/2006-05/2008 Director, Quality Management
Conducted Quality Improvement Activities and studies on specific utilization and quality issues identified as consistently requiring opportunities for improvement.
Conducted oversight audits to sub-delegated organizations for utilization management, credentialing, customer service activities and claims processing.
Assumed responsibility for all RFPs and State related responsibilities related to quality.
07/2003-01/2006 Quality Management Manager
Conducted Quality Improvement Activities on specific utilization and quality issues identified as consistently requiring opportunities for improvement.
Increased operational efficiencies within the Quality Management department by creating a cross-training program and ensuring all staff were cross-trained.
Created an audit tool to monitor compliance with contractual requirements for complaints, appeals and Fair Hearing processes.
Integrated Behavioral Health (BHO), Dallas, Texas
03/2003-07/2003 Consultant
Analyzed potential business opportunities that existed in Texas for Public sector programs by creating a Market Analysis and Strategic Action Plans for both Medicaid and Medicare.
Magellan Behavioral Health (BHO), Dallas, Texas
10/2000-12/2002 Quality Improvement Manager
Project management and development responsibilities for ensuring URAC standards were followed and NCQA accreditation compliance was obtained and maintained.
Ensured annual compliance audits from Health Plans as well as State and Federal agencies meet regulations and contractual requirements.
10/2000-10/2001 Program Account Manager
Account Management responsibilities that included interaction with Health Plans and State Agencies to discuss performance, corrective actions, and medical coordination issues.
Ensured compliance of Health Plan contractual requirements on utilization management, quality improvement, and claims processing as well as State and Federal regulations developing and implementing interventions for items that were out of target ranges.
04/1999-10/2000 Operations Manager
Worked with State Agency Directors to assess efforts and define data collection procedures.
Develop a marketing plan and budget for materials for providers and members of Medicaid Project Manager for the simultaneous startup of three new Medicaid contracts.
11/1996-4/1999 Network Development Manager
Implemented programs to develop and maintain positive relationships between health plan, hospitals, ancillary providers and administrators.
Managed an implemented the health plans reimbursement and negotiated strategies in conjunction with the Medical Expense Team Demonstrated expert negotiation skills.
ProPsych (BHO), Nashville, Tennessee
05/1994-11/1996 Network Development Manager
Managed an implemented the health plans reimbursement and negotiated strategies in conjunction with the Medical Expense Team.
Supervised the staff that credentialed providers according to NCQA standards and provider and member complaints resolution teams.
Education
12/2000 University of Phoenix Master Degree: Business
Masters of Arts in Organizational Management
05/1990 Ball State University Bachelor Degree: Criminal Justice and Criminology
Bachelor of Science
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