PATRICIA CONDOS RESUME

Patchogue, NY Email – ac214x@r.postjobfree.com Phone – 631-***-**** (home) 631-***-**** (cell)

PROFILE SUMMARY

A licensed nurse, skilled leader, and detail-oriented professional with strong interpersonal skills and extensive

experience in quality control and regulatory compliance management, providing outstanding service to clients,

healthcare providers, and facilities with a keen focus on NCQA compliance and quality improvement; equip with

the capabilities of a data analyst who can spot trends and enact policies and procedures to streamline processes

that deliver on the bottom line.

Bilingual (Spanish, English) Credentialing Certified Grievance & Appeals Specialist

Coding Certified HEDIS STAR Measures SME Project Management

Data Analysis Staff Training & Leadership Problem Resolution

EXPERIENCE & NOTABLE CONTRIBUTIONS

EMBLEMHEALTH, Melville, N.Y.

Medicaid Quality Improvement Program Manager –January 2017 – Present

The primary functions as Medicaid Program Manager entail the development, implementation, and monitoring of

quality improvement programs, systems and initiatives to facilitate performance and process improvements, to

increase Medicare Stars, Quality Incentive Awards, Quality Plan Rankings, and Accreditation Status impacting the

entire Organization; while maintaining knowledge of all product lines (Medicare, Medicaid or QHP/Commercial);

and up-to-date knowledge and understanding of HEDIS/QARR measure technical specifications, Accreditation,

CMS Star Ratings, and Medicaid Quality Award Programs.

OTHER KEY RESPONSIBILITIES

• The design and implementation of all initiatives, projects, and action plans related to regulatory and accreditation mandated performance improvement project(s), reporting requirements for CMS, NYS DOH, FEHBS, NCQA and URAC for all applicable product lines.

• Overseeing project implementation to meet corporate goals for Medicare, Medicaid, QHP, and Commercial product lines for HIP and GHI, while serving as the primary contact / resource for all quality based regulatory reporting.

• Manage and update Quality Improvement Program Description (QIPD), Quality Improvement Work Plan (QIWP) and develop the Quality Improvement Program Evaluation (QIPE) for applicable product line.

• Regularly monitor regulatory / government policy and methodology updates and industry news to assess and address potential impact to the organization from changes related to the product line.

ARCHCARE HEALTH PLAN, New York, N.Y.

Quality Improvement Manager – MLTC Grievance & Appeals (Contract Role) – 2016

This role entailed a comprehensive involvement with Grievance, Appeals and Fair Hearings, dealing with OTDA calls and DOH complaints, with the goal of same day Grievances to maintain the time frame, compliance, and turn-around allotments to meet regulatory guidelines. I worked collaboratively with the Utilization Management and Care Management departments regarding IAD letters, and investigated grievances as per protocols, to resolve and give our members the best understanding of their care and benefits.

KEY ACCOMPLISHMENTS:

• The development and monitoring of the Grievance and Appeals process in accordance with State requirements and mandates.

• Implementation, development, and maintenance of a standardized quality management plan and program to ensure compliance with external regulatory and accreditation requirements.

• The establishment, maintenance, and monitoring of systems to evaluate health care quality improvement activities according to regulatory requirements, accreditation standards, policies and procedures and contractual agreements.

• Designed methodologies for preventive care and health care evaluations.

• Conducted preventive studies to evaluate the coordination of care and to assess the quality and utilization of health care services.

• Provided assistance and guidance to clinical staff with regard to methodology, data analysis and reporting.

• Managed and evaluated performance of staff related to clinical and health care services performance improvement activities.

• Coordinated guidelines, studies, and performance improvement activities with the utilization management, quality management, case management, and disease management programs.

• Compiled and prepared monthly and quarterly reports for quality committee reviews as well as annual update on state Plan Risk Management Program Description and reports for confirmed adverse incident and RCAs.

• Participated in the development, review and updating of policies and procedures.

• Provided ongoing staff development, and new hire orientation.

• Maintained knowledge of HEDIS requirements and specifications, implementing clinical performance methods to improve HEDIS performance.

ANTHEM BLUE CROSS, BLUE SHIELD, New York, N.Y.

NYS HEDIS Medicare Project Manager – 2014 to 2016

In this role I directed the Annual HEDIS Quality and Star Measures Project, by implementing production, productivity, quality, and customer-service standards; spearheaded the recruitment, training, and overall supervision of quality assurance team members and 23 temps annually; and utilized data analysis as the primary trouble-shooter, consistently identifying and resolving problems that could harm the overall quality control process, and informing peers, senior management, and providers on progress. Collaborate with Risk Department on RAF and HCC.

KEY ACCOMPLISHMENTS:

• Planned, developed and implemented quality control policies, procedures, and practices by conducting hazard analyses, identifying preventive measures, establishing critical limits, monitoring procedures, enacting corrective actions, and ensuring verification procedures.

• Utilized quality control reports to develop summary documentation and reports to identify trends and areas for improvement.

• Conceptualized and enacted new policies and procedures focused on streamlining quality control processes, exceeding corporate financial goals, and meeting all production goals for the team.

• Initiated the first SFTP and EMR implementation in collaborating with large volume and hospital providers.

• Liaise directly and manager external vendors.

CENTERLIGHT HEALTH, Bronx, N.Y.

Regional Quality Manager – 2013 to 2014

Coordinated LHCSA, CHAA, PACE, SELECT, ADC, and on-site audits for healthcare clients and organizations. Ensured all on-site resources to work directly with infectious disease reporting and resolution, as well as incident reports. Liaised with CMS to monitor, identify, and analyze root cause analyses.

KEY ACCOMPLISHMENTS:

• Provided essential support to the Education and Compliance department, focusing on identifying and delivering key information to patients and healthcare providers.

• Liaised directly with PACE and SELECT/DIRECT centers to ensure overall compliance with Medicare and Medicaid objectives.

COMPLEXCARE SOLUTIONS, Brooklyn, N. Y.

Client Quality and Compliance Manager – 2012 to 2013

Directed the overall quality assurance of documentation, policies and procedures, programming, and overall operational excellence for healthcare clients and organizations. Utilized statistical data to develop reports to stakeholders on quality assurance successes. Performed essential New York state and federal reporting for all team employees.

KEY ACCOMPLISHMENTS:

• Conceptualized, developed, and implemented policies and procedures based on corporate standards and federal regulations.

• Drove the development of staff, and provided essential leadership to ensure consistent quality control and a cohesive team atmosphere.

• Ensured the overall success, compliance, and coordination for internal and client audit procedures.

AMERIGROUP/HEALTHPLUS, New York, N.Y.

Quality Manager – 2009 to 2012

Performed essential reviews and quality over-reads for healthcare providers, sites, facilities, medical records, and other associated medical materials, personnel, and documents. Liaised directly with corporate stakeholders, care providers, and other staff to ensure seamless audits, and to relay results of reviews.

KEY ACCOMPLISHMENTS:

• Planned, developed, and delivered essential education and training sessions to providers to provide insight and updates to Medicaid/Medicare NCQA/IPRO and NYDOH standards, and to ensure compliance with HEDIS/QARR audits.

• Acted in compliance with HIPAA regulations in all matters.

• Directed and supervised temporary employees during special projects, providing essential feedback and performance appraisals.

MEDASSURANT, New York, N.Y.

Onsite Nurse Reviewer Medical Audits – 2006 to 2009

Directed onsite and remote reviews of healthcare providers and client files while working in accordance with Medicare and Medicaid regulations. Analyzed client charts, records, and documentation to ensure clarity and appropriate medical terminologies. Liaised directly with healthcare providers to identify, gather, and analyze pertinent medical information for each client.

KEY ACCOMPLISHMENTS:

• Acted in compliance with HIPAA regulations, and ensured that all medical records were handled like legal documents.

• Performed time-efficient, target-focused reviews of client files, and delivered feedback to stakeholders.

EDUCATION & TRAINING

Certified: CPDN and CHT Dialysis Nurse

Certified: AAPC

TECHNICAL PROFICIENCIES

Microsoft Office Cara SRSA FACETS CATALYST PEOPLESOFT SHAREPOINTS MRDB DCT Adobe Parallels .Cmap MaxMC Caresync

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