Management Project

Stephanie Lampley, RN, BSN

**** ******* ***** ******: 615-***-****

Brentwood, TN 37027 ***********@*****.***

PROFESSIONAL SUMMARY

Healthcare Professional with extensive background in diverse healthcare settings including, hospital and integrated managed care environments. Proven leadership skills in challenging and changing environments with multisite responsibility, seeking high-level position with innovative organization where I can bring the following core competencies in order to drive the success of the organizational goals.

Utilization Management

Care Management

Long Term Services & Support

Appeals & Grievances

Population Health

Customer & Client Support

Managed Care

Operations

Regulatory & Compliance

Policy Development

Process Improvement

Project Management

PROFESSIONAL EXPERIENCE

Evolent Health Arlington VA 4/2015-2/2017

Director Utilization Management, Regulatory and Compliance

Managed remote team of UM Clinical Auditors and UM analyst and Assistant Director Medical Policy Programs.

Developed and implemented Quality Audit Program to ensure compliance with health plan utilization management operations on behalf of Evolent Health’s clients in local markets for Commercial/Individual, Self-Insured, Medicaid and Medicare Advantage products including Dual SNP and Chronic SNP products.

Developed and implemented UM policies, Standard Operating Procedures and client Medical and Pay policies for UM department start up to ensure compliance with applicable State/Federal laws and regulations.

Delivered strategic guidance to Utilization Management team based on regulatory releases for functional UM activities as they related to compliance, regulatory, and government affairs.

Monitored UM metrics for compliance with State/Federal regulatory requirements as well as NCQA standards.

Conducted Inter Rater Reliability (IRR) Assessments (Interqual/MCG) for nursing and medical director staff.

Managed the state/federal regulatory and compliance functions that support NCQA accreditation, URAC, and CMS Medicare Advantage compliance guidelines that are supported by evidence- based practices and client medical & pay policies.

In collaboration with UM Medical Directors, developed, implemented and provided oversight of the Medical and Pay policy program.

In collaboration with Compliance team conducted annual delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the contractual agreement.

Led Utilization Management readiness reviews and UM related audits including NCQA, CMS Medicare Advantage and URAC audits.

Successfully led team through NCQA audit and NCQA re-accreditation

Successfully led team through two CMS Medicare Part C audits, no fines assessed.

Monitored key performance measures and provided issue identification, problem analysis and strategies for performance improvement.

Responsible for project management of all corrective action plans and monitoring to ensure implementation of process improvement initiatives and compliance with regulatory requirements.

Developed training for Utilization Management staff through e-learning.

Position eliminated due to RIF.

UnitedHealth Group – Various Entities and Locations 10/2002-4/2015 Community Health Plan of Tennessee Nashville, TN 11/2012-4/2015 Statewide Health Services Director for Long Term Services and Supports

Statewide management of remote team for Tennessee Medicaid (TennCare) CHOICES Long Term Services and Support program, including support for 25 non-clinical staff, utilization management nurse, 215 clinical care coordinators, 15 Managers and 5 Directors.

Ensured compliance and goals/targets are met for both Federal/Medicare (Dual Special Needs Plan), State Medicaid and NCQA requirements.

Developed and executed strategies/operational objectives for the CHOICES program including care coordination, financial accountability and customer (Member and State Partner) satisfaction.

Responsible for development of Policies and Procedures, Standard Operating Procedures to ensure compliance with regulatory requirements.

Project managed multiple projects to ensure key business segment objectives were met and were compliant with Federal and State requirements.

Identified and drove local Healthcare Affordability Initiatives by partnering with the Medical Director(s) and clinical team.

Coordinated Population Health activities across the matrix organization inclusive of Behavioral Health and High Risk Case Management.

Implemented process to ensure “gaps in care” were addressed

Led/coordinated all audits both internally and externally.

Led, coached, and developed clinical leadership staff. Community & State by UnitedHealthcare Remote National Position 1/2010-11/2012 Associate Director Medical and Clinical Operations

Project managed and coordinated all activities related to the UHC Medicaid and Dual Special Needs Plans for Prior Authorization and Grievance & Appeals functions for multiple health plans, ensuring operational contract compliance as defined by Federal and State contract.

Coordinated with UHC Community & State Health Plan Leads and Operational leads, serving as the primary point of contact for 6 States. (Tennessee, Florida, Texas, Washington DC, Mississippi and Louisiana)

Worked closely with the UHC Benefit Operations and United Clinical Services (UCS) cross functional teams for Appeals and Grievances to accomplish organizational goals and to meet the contractual needs as defined by Federal and State contracts.

Conducted gap analyses on large noncompliant cases to understands root cause for non- compliance with State requirements, as well as developing action plans to address the issues/gaps with the cross functional teams.

Developed and executed project plans to improve existing performance and efficiency in operational processes.

Lead large, complex projects to achieve key business segment objectives including Dual Special Needs Plans (DSNP) program development.

Oversight of the operational aspects of new product implementations to ensure contract compliance.

Monitor performance results and work with the cross functional team on addressing gaps in performance.

Serves as the regions end to end Prior Authorization and Grievance & Appeals subject matter expert and point of contact for the implementation of new health plans and products.

Provided support and coordinates with UHC Benefit Operations and United Clinical Services for any Prior Authorization/G&A needs in health plan State audits. AmeriChoice by UnitedHealthcare Nashville, TN 12/2007-1/2010 Director Utilization Management/Interim Vice President of Health Services

Provided temporary oversight for 3 months of 90 FTE’s including managers and staff for Utilization Management, Case Management, Disease Management, Maternity Program, ED Diversion, Private Duty Nursing and non-clinical functions for all health services.

Managed 500,000 TennCare lives in a start-up environment.

Provided ongoing oversight of 42 FTE’s including managers and staff both non- clinical/clinical (Medical Review Unit (Reimbursement team), Clinical Letter Compliance Team, Appeals and Grievances and Non-Clinical Support Team).

Health plan liaison with Prior Authorization department, call center, provider disputes and claims department.

Implemented operational efficiencies to ensure compliance with TennCare, Dual Special Needs Plans/CMS, Hawki childrens’ programs and reporting requirements.

Oversight of CMS and NCQA audit process for Appeals and Grievances.

Implemented the organization’s utilization management plan in accordance with the mission and strategic goals of the organization, Federal, State law, and accreditation standards.

Assisted with the development of policies and procedures for Utilization Management, appeals & grievances for all product types.

Coordinated health plan policies and procedures with both claims and call center department to ensure compliance with State, Federal and NCQA requirements.

Implemented Population Health Program for Health Services team.

NCQA Excellent rating for 2009.

AmeriChoice by UnitedHealthcare Nashville, TN 3/2007-12/2007 Market Deployment Manager

Responsible for project proposals in a start up environment for Case Management/Utilization Management programs. Determined time frame, funding needs, procedures for accomplishing project, staffing requirements and the allotment of resources to various phases of the project.

Directed and coordinated activities of project personnel to ensure project progress was on schedule and within budget.

Prepared project reports for senior management.

Recruitment and assignment of project personnel.

Successfully led 11 projects to completion.

Uniprise by UnitedHealthcare National Position 10/2005-3/2007 Assistant Director Central Escalated Unit

Provided oversight of 74 supervisors and staff, both clinical and non-clinical.

Collaboratively worked with leadership team on Human Capital initiatives including compensation planning, performance management, staffing and employee relations concerns/issues, employee recruitment, training, teaming and employee development.

Provided operational oversight and project management expertise to facilitate the integration of the appeals, complaints and denials process for mergers and acquisitions primarily of government programs (AmeriChoice).

Established collaborative relationships with internal and external customers to ensure customer satisfaction and timely complaint resolution with business partners to identify opportunities to improve business processes.

Partnered with Compliance Manager to develop policies and procedures, job aides, and training alerts to implement compliance-driven initiatives and meet regulatory requirements.

Assured compliance with State and federal regulations relating to complaint and appeals processing.

Implemented operational efficiencies to ensure compliance with corrective action plans for both commercial and government programs.

Provided timely and accurate reporting to regulatory/accreditation agencies.

Implemented operational efficiencies based on weekly/monthly metrics, which resulted in improved quality and turnaround time metrics.

Reduced days to process from an average of 20 days in January 06 to an average of 4.1 days November 06.

Improved quality metrics for determination accuracy: January 06 DPMO 122807 reduced to DPMO 15228 October 06.

Improved correspondence accuracy from an average of 48% in January 06 to an average of 92% in October 06.

Manager, Provider Appeal Operations Columbus, OH 10/2002-10/2005

Oversight of 6 clinical staff and 12 administrative staff, including recruitment, performance management, employee relations concerns/issues, training, teaming and overall employee development.

Provided oversight and direction to clinical Cost Containment Analysts for provider appeal resolution.

Developed and implemented clinical training program for RN, Cost Containment Analysts.

Collaborated with management team daily to ensure teams were meeting performance and quality metrics.

Facile with CPT, HCPCS and ICD-9 coding and billing procedures for professional medical services.

Facile with UnitedHealthcare Reimbursement policies and Medical Policies. Employment History Prior to 2002 Available Upon Request EDUCATION

Bachelor of Science Degree, Nursing, Ohio University, Athens, Ohio June 1996

Associate Degree, Nursing, Ohio University, Athens, Ohio June 1994

Bachelor of Science, Organizational Communication with a Business Minor, Ohio University, Athens, Ohio June 1990

PROFESSIONAL LICENSURE

Tennessee State Board of Nursing, Registered Nurse (Current) COMPUTER SOFTWARE

Proficient in Microsoft Outlook, Excel, Word, Power Point Project Viso and Sharepoint

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