SUMMARY

Healthcare executive with extensive experience in strategic planning, clinical and administrative operations, compliance and regulatory adherence, P&L, Behavioral health, Provider relations, accreditation, and quality improvement. Proven ability to enhance profitability through affordability initiatives. Possesses in-depth operational knowledge to produce efficient, effective, and measurable results. Exceptional analytical skills that support root cause analysis effectuating positive solutions. Excellent leadership and management skills yielding the ability to motivate, coach, and build cohesive teams.

PROFESSIONAL EXPERIENCE

May 2023 – Present, Senior Clinical / Strategic Consultant

Responsibilities included providing strategic direction to organizations regarding Prior Authorization, Utilization Management, Case Management, Appeals and Grievances, Quality, Compliance, Regulatory, Communications Behavioral Health and Pharmacy

May 2007 – April 2022

Senior Vice President, UnitedHealth Group

Responsibilities included Prior Authorization, Census Data Unit, Utilization Management, Case Management, Appeals and Grievances, Quality, Compliance, Regulatory, Communications and Pharmacy

Development and implementation of utilization and case management program standards for all health plans nationally and internationally

Responsible for compliance and regulatory performance regarding all aspects of business segments (primary care, ACOs, health plans, home care organizations, hospitals, post-acute and home programs, etc.)

Responsible for compliance and regulatory requirements in all lines of business (Medicare, Medicaid, Commercial to include FI and ASO)

Responsible for internal and external auditing in all lines of business (Medicare, Medicaid, Commercial to include FI and ASO)

Implementation of UM and CM health care quality and affordability initiatives

Development and implementation of UM and CM policies and standard operating procedures

Performed root cause analyses to obtain operational efficiencies

Maintained health plan and national clinical performance metrics and developed mitigation strategies

Lead in NCQA and URAQ accreditation process

Leader in the EQRO process

Championed the RFP process through implementation to completion

Implemented and managed clinical learning and development programs for frontline, middle management, and executive leaders

Extensive Managed Care knowledge: Medicaid, Medicare, Commercial and Long-Term Care

Provided national support to the Long-Term Care business

Developed strategic goals and clinical programs in alignment with enterprise-wide strategic vision

Quality Oversight including build of Stars initiatives

Responsible for relationship and Oversight with programs including building out best practices for Transitional Case Management, NICU, ESRD and CHF

Identified and execution of health care cost initiatives throughout organization

Ownership of operational excellence for national clinical operations

Senior leadership role managing Physicians, Nurses, Social Workers, and non-clinical staff.

Managed relationships with over 6000+ hospitals and hospital systems nationwide

National leader in negotiating with hospital systems, ACOs, Primary Care and home care organizations to drive

out unwarranted variation and standardizing practices to drive efficiency and quality outcomes.

February 2001 – January 2007

Vice President, Health Services, Coventry Health Care of Delaware, Wilmington, DE

Responsible for Prior Authorization, Inpatient Case Management, Complex Case Management, Disease Management, Post-Acute Management, Home Care Coordination, Administrative and Clinical Appeals, Quality Improvement, Compliance, Risk Management and Department of Insurance inquiries for Commercial, Medicare and Medicaid product lines for the State of Delaware

Managed relationships with all Participating hospitals and hospital systems

Overall accountability for the utilization management of all levels of care and identified opportunities for improvement through quality improvement initiatives

Collaborated with all levels of finance department to identify fiscal responsibility including departmental

expense, salary, and capital budgeting

Responsible for IOI and affordability initiatives

Maintenance of State relationships

Responsible for contracting initiatives and identifying network gaps and opportunities in the State of Delaware and surrounding states

Leadership role in obtaining URAC accreditation for the Delaware Health plan

Leadership role in State of Delaware EQRO audits

Developed and implemented multiple systems within the organization to track and trend data by use of clinical informatics

Identified strategic opportunities for improvement through application of data

Identified quality improvement opportunities through root cause analysis and improve overall outcomes of member population

Recruited at a corporate level to assist 25+ Health Services Plans for accreditation completion

Provided direction and mentoring to the company health service leaders for outstanding results.

April 1997 – February 2001

Director of Case Management / Home Care Coordination, Underwood-Memorial Hospital Woodbury, N.J.

Development and implementation of hospital wide case management program to enhance services, improve customer satisfaction, improve quality, and identify risk management with coordination of service.

Identified quality improvement initiatives while increasing fiscal accountability.

Provided leadership directing a team of case managers, social workers, and home care coordinators to assess and coordinate each patient’s continuum of care needs within an integrated health system

Developed quality and strategic initiatives to decrease risk, improve quality and to manage utilization of services through tracking and trending of data for multiple managed care companies, Medicare, and Medicaid populations

Collaborated with all levels of the finance department to identify fiscal responsibility including departmental expense, salary and capital budgeting.

Developed new contracts and standardized contracts between the hospital and managed care companies

Expanded integrated health services assisting with the development of a Transitional Care Unit and Home Care Company

Liaison between hospital and managed care companies to ensure approval and continued approval of hospitalization

Statistical reporting to all levels of management

Completed JCAHO accreditation with full compliance in all standards

Previous positions also include:

Director of Case Management / Quality Improvement, Prison Health Services, New Castle, DE

Case Manager, Skilled and Rehabilitation Facility, Mt. Sinai Hospital, Philadelphia, PA

Medical Writer, Emergency Medicine Magazine, New York, New York

EDUCATION

Bachelor of Science in Nursing, Neumann College, Aston, PA

Master’s in healthcare administration, Kennedy-Western University

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