Velvet Thorne

High Bridge, New Jersey ad3kep@r.postjobfree.com Cell Phone - 732-***-****

PROFESSIONAL SUMMARY

Velvet is a seasoned Healthcare and Pharmaceutical Professional with diverse experience in all areas of population health management. She has extensive provider engagement experience with data science, quality (HEDIS STARS measures), risk, case, disease, and utilization management, as well as care coordination. She has a demonstrated track-record in impacting value-based payment initiatives. Velvet has supported healthcare clients to include Atlantic Health Systems, United Health Care, Horizon Blue Cross Blue Shield, HealthEC, and AmeriHealth. Velvet has a better, more cost-effective approach to care using business strategies, state-of-the-art healthcare systems, practices and algorithms across large MCOs & ACOs enterprises. Velvet is a published blogger for Care Coordination and patient engagement initiatives.

PRODUCT, REGULATORY & OPERATIONAL EXPERIENCE

Payer Programs

Medicare Protocols

Medicare

Medicaid

Medicare Advantage

Medicaid HMO

Commercial

Medicare Shared Savings

Medicare A (hospital)

Medicare Part B (outpatient ancillary services)

Part C (Medicare Advantage)

Part D (Prescription Drugs)

ST/ LT Disability

Workmen’s Compensation

No- Fault SIU Investigation

•Population Health Management:

oQuality/Risk Management

oUtilization Management - Perspective, Concurrent, and Retrospective Reviews (Ten Years Experience)

oCase/Disease Management

oCare Coordination

• Regulatory:

oTrained by civil trial attorneys on medical malpractice in TORT Laws and medical chart review for causation in National and State (NY & NJ) Malpractice laws

oKnowledge of Medicaid laws related to DOHHS, AHA, CMS, MACs, OIG, and NCHS

oCoding rules pertaining to outpatient clinics, private practice and inpatient settings

oCPG, URAC, NCQA, HIPAA and OSHA

oPerformed Pharmacy Covigilance - Patient Adverse Events

oNational Standards of Care for various disease initiatives through DHHS, CMS

oNCQA, URAC rules and all federal and state pharmacy compliance regulations

TECHNICAL EXPERIENCE

Encoder

Med Capture

Med Decision/Care Planner

Cosmos

HTA

Atlas, HAT

CPW

Jabber

Pyramid

IST

On-Base Tru Care

McKesson

NIC

EPIC Case Management

EPIC Elbow Support

EPIC clinDon

EPIC Secure Chat

Practice Fusion Elbow Support

Uniflow

CCMS, SQL, SAS

Facet, Macess

Medi Track

Care Optimize

DIAMOND

BEN

Advancer

CPS, MAPP, UNICON

MHS

UNET, Jabber, Microsoft Teams

KDJ, ECAA, PSYCKES

Navient

EPaces, ECG, Citrix, Hot Spotting Impact

PCS, ICUE

MDA/REEDS

CCPRO & 3D Analytics

CCM Platform Designs

Process Improvement Workflow Design

Community Care Legacy

Tableau Care One

Microsoft Office Suite

PROFESSIONAL EXPERIENCE

Atlantic Health System/Talent Software Services

CASE MANAGEMENT CONSULTANT November 2022 – February 2023

●Performed patients assessments and facilitated the discharge planning process.

●Educated inpatient case managers about CMS Triple Aim Theory

●Developed a multi-disciplinary, culturally appropriate, age-specific discharge plan.

●Assessed and documented patient’s SDOH for additional care needs.

●Used the EPIC EMR system for documentation, electronic communication and secure chat.

●Performed Initial and continued stay reviews.

●Used Milliman Care Guidelines and medical decision making.

●Attended and participated in medical and continued stay rounds.

●Collaborated with the care team about complex cases.

●Initiated case and disease referrals to facilitate transitional care

●Facilitated transitional care for private pay patients and provide patient education.

●Initiated homecare services, durable medical equipment, IV infusion and enteral feeding.

●Educated patients about universal precaution, importance of having a primary care physician to promote annual wellness, chronic care management visits and self care monitoring.

●Presented and discussed New Jersey State and NCQA HEDIS star quality measures (AAP_ Adult Access Preventive Ambulatory Care and Transitional care_ TRC) to ensure metrics are documented and to facilitate timeliness of care treatment services.

●Focused on patient access to care at the right time and place for the right reasons.

United Health Care Group.

HEALTH HOME TRANSFORMATION CONSULTANT February 2022 – September 2022

●Responsible for the Institution for Family Health (IFH), Hudson Valley Coalition (HVC), Children’s Health Home Upstate New York (CHHUNY), ONODAGA, and New York Community Health Home (NYCHH)

●Accountable for successful deployment of UHC’s Clinical Support program at the practice level, including but not limited to, introducing and educating practices on the value/use of reporting tools, patient registries and delivery of reports via UHC’s Technology Portals Build and effectively maintained relationship with the practice leadership and key clinical influencers actively involved in practice transformation

●Regularly facilitate efficient, effective practice improvement meetings with the practice to monitor, present, and discuss progress on the transformation action plan and achievement in milestones.

●Developed strategies based on performance analysis, for improvement that includes specific outcomes and metrics to monitor progress to a goal and make recommendations for improvement

●Designed practice transformation action plans and implemented appropriate performance improvement initiatives designed to assist the practice in achieving contractually required transformation milestones.

●Monitored and reviewed the progress of the practice in milestone achievement and ensure the practice is accountable for successful completion Where outcomes are below goal identified outlier member files for focused action plans

●Audited of Health Home assessments and member care plans to ensure compliance with regulatory requirements

●Use data to analyze key cost, utilization and quality data and interpret results to assess the performance of the practice

●Used data to analyze trends and work with stakeholders to agree on and implemented proactive strategies to address issues, and measure impact using a Plan-Do-Study-Act (PDSA) rapid cycle improvement approach; including external practice data Educated & Deployed technology tools to support Practice Transformation

●Build and effectively maintain relationships with. team members in the UHC Clinical organization as well Medical Directors, local Network leads, Health Care Economic Analysts and Clinical Analysts in support of the program Consult and partner with internal UHC matrix partners and the practice to identify organizational and structural challenges hindering achievement of desired program outcomes

●Collaborated with UnitedHealthcare teams including the Practice Care Coordinators, quality management teams, hospital clinical teams, behavioral health teams to support whole person care for our members with practices and hospitals.

●Assisted and supported department leaders in summarizing and disseminating experience related learning by way of team updates, written reports / articles, and / or presentations as called for by directors.

●Ensure all required member documents as indicated in the Community and State UnitedHealthcare contract for Health Home programs

●Monitored ER and IP utilization and to ensure the timeliness of care coordination and discharge planning efforts.

●Referred Medicaid member to Home Community Based Services

●Performed Chart Audits, participate in Integrated rounds and follow up on Interdisciplinary Team meetings

●Receive and transmit ADT, member roster, member data and gaps in care reports.

Integrated Resource Inc. Temporary Contract

EMBEDDED CLINICAL QUALITY IMPROVEMENT LIAISON ANALYST January 2021 – January 2022

●Assigned to both ACOs Atlantic Health Systems and Optimus Healthcare (30+ practices).

●Primary liaison for the Customer’s quality management department and assigned provider groups to improve HEDIS and Stars quality performance.

●Support Customer’s change management that will impact the quality of care provided in practices.

●Monitor and analyze provider quality performance reports. Identify areas of improvement, aid with root cause analysis, assists with developing solutions, and develop a work plan to monitor progress.

●Conduct provider on-site visits on a regular basis, as mutually agreed, to implement a work plan and to conduct provider education sessions regarding appropriate coding practices and chart documentation.

●Assist with coordination of care for identified outpatient members/patients (telephonic or face-to-face member contact, schedule preventative appointments or follow-up evaluations, confirm with patient if prescribed medications are being taken as directed, and update the patient’s medical record with current information as appropriate.

●Assist discharged members/patients with transition of care process, by contacting patients within 24-48 hours after discharge to schedule follow-up with the primary care physician, confirm with patient if prescribed medications are being taken as directed, educating members/patients about health care system services available, confirm hospital records are received by the provider/practice and updating the patient’s medical record with current information as appropriate.

●Update the patient’s medical record with recommendations from member/patient’s specialists as appropriate.

●Collaborate with value- based programs and provider contracting and services to manage provider quality performance.

●Share available Customer’s community services and resources with the providers/practices.

●During HEDIS season, assists with the retrieval of charts, chart abstraction, and chart review entries.

●The clinical quality measure will adhere to the HEDIS guidelines for chart review abstractions and standards.

●Provide HEDIS provider guidelines highlighting appropriate HEDIS codes for claims submission.

●Assist with optimizing the use of the practice's electronic medical record (EMR) system to close care gaps; and assist in the development of new strategies for member/patient and provider outreach, engagement, and education materials to improve quality performance.

●Oversight leader for quality governance committee

Healthec

POPULATION HEALTH/MANAGER OF CARE COORDINATION April 2017 – January 2020

●Responsible for all front-line patient/provider engagement initiatives for AICNY LLC (“The Alliance for Integrated Care of New York”) a CMS-approved Accountable Care Organization

●Efforts resulted in cost- savings of $2 million/year for the ACO

●Direct Responsibilities for the ACO included:

oReducing healthcare utilization/cost on top 5% high-risk Medicare beneficiaries and improving patient outcomes

oCaptured CMS and NCQA clinical quality-measure data

oQuality Data Analytics and Practice Transformation

oSuccessful risk management and cost-containment

oStrategic attribution management

oDevelop client strategies and processes that align with CMS, NCQA and PCMH

oCreated corrective action plans for improvement across the ACO

oCommunicate with hospitals regarding discharge planning, primary care follow-up readmissions mitigation

oCreated CCM (Chronic Care Management) program and AWV (Annual Wellness Visit) initiatives for private practices and their high-risk patients

●Create and manage marketing blog for Health EC

●Client presentations on care-coordination initiatives

●Participate in forums, to identify and articulate trends in healthcare reform

●Use of HealthEC Population Health Management (PHM) platform to educate providers, nurses, and administrative staff on how to effectively utilize HealthEC’s digital platform

●Train new hires as care coordinators:

oData analytics

oCare coordination

oPractice transformation

Aerotek/EXL Healthcare - Amerihealth (Contract)

PHYSICIAN ENGAGEMENT NURSE June 2016 – April 2017

●Responsible for physician engagement throughout Camden, Mercer, Gloucester and Burlington counties

●Scheduled 4 to 5 practice visits/day to provide cost comparative reports for primary care and specialist providers

●Delivered AmeriHealth plan value -based care initiative to practice gatekeepers

●Reviewed physician reports (i.e., gaps in care, ER/hospitalization utilization and generic drug substitution)

●Participated in HEDIS audits, chart reviews, overreads, CDC CBP AWC measures

●Engaged providers in cost-containment initiatives

●Escalated provider complaints to provider relation representatives

●Documented and reported suspicious activity via fraud-line and prepared corrective action plan reports.

Paragon Search & Strategies, LLC

SENIOR PROJECT HEDIS NURSE February 1989 – June 2016

●Clients Included:

oHealth First

oAffinity Health Plans

oAqurate Health Data Management Inc.

oUnited Healthcare

●Performed medical chart reviews, data extractions

●Responsible for overreads for HEDIS via Altegra Inc., Med Captured tool, QHRS, and Record Flow

●Medical record audits and compliance:

oDocumented events in accordance with NCQA regulations

oUse random patient samples to verify ICD9/10 and CPT coding errors

Educated providers on proper coding and its impact on their revenue stream

●Educated private practice and institutional provider on NCQA, fraud and compliance education

●Escalated insurance claims to management

●Participated in HEDIS reporting requirements and created a process improvement workflow design

●Mentored and train new hires system applications, share drive, mapping, SOPs, Web Ex claim database, excel, outlook tools as well as NCQA guidelines and measures

Independent Contractor

NURSE CARE ADVOCATE FOR CMS MEDICAID BENEFICIARY (REAL WORLD CASE PROJECT) May 2015 – November 2015

●Documented patient complaints, history & physical and treatment plan

●Assessed patient socioeconomic status and made social service referral to initiate completion of documents in lieu of SSI Disability insurance determination

●Provided community/private resources for temporary support

●Identified gaps in and continuity of care

●Encouraged Primary Care Physician and care team follow up visits

●Filed provider complaint with CMS and Division of Health Human Services

●challenges with access

oTimeliness and assessment of care which caused frequent ER visits and hospitalizations

oSuccessfully navigated patient healthcare access

oAssists patient with enrollment into health plan case management program

oResearched and procured new PCP provider

Contacted PCP and care-team specialists to develop care-plans and assist with coordination of care

Transported patient to/from medical appointments and local food banks

●Provided continuous patient education

Partners In Care, INC.

NURSE CARE COORDINATOR December 2008 – November 2014

●Responsible for healthcare cost reduction through better care coordination

●Performed assessment of claims data to identify:

ogaps in care

ohospital “frequent flyers”

oover/under utilization of care service

Medication

Case and Disease Management services

●Formulated effective care plans to improve positive clinical outcomes

●Researched and reported medical adverse events and medication contraindications to Quality Review Board and network providers

●Managed 500+ cases while maintaining production yield of 90% for multiple clients, including:

oAetna

oHorizon BC/BS

oCigna

oMedicare ACO

oSelf-insured plans

●Initiated Six Sigma projects in multiple disease states using PDCA (plan do check act) tool, including pediatric obesity and early pediatric diabetic screening

●Led process improvement project initiatives used DMAIC (Define Measure Analyze Improve Control) tool

●Participated on Cigna Health utilization board meeting

●Served on Company’s quarterly (SME) Quality Performance Board Committee:

oReview standards of care

oClinical practice guidelines

oPatient- provider issues and complaints

●Developed and maintained relationships with staff and physicians

●Effectively worked with PIC Medical Director and Pharmacist to drive improved clinical outcomes and overcome barriers to care

●Provided lead generation to the Senior Network Account Manager for recruiting into the (UMG) United Medical Group provider network improvement

●Enhanced initiatives via practice numerous onsite visits to communicate MDs, NP’s, PA’s

oClinical documentation

oClinical practice SOC guidelines

oTermination of care protocols

oPatient outreach protocol

oPatient education handouts

oComplex patient care-plans

New York Presbyterian/Weill Cornell Medical Center

COMPLEX/CATASTROPHIC MEDICAL/HIV AIDS/DIABETES NURSE CASE MANAGER (TELEPHONIC) August 2005 - November 2017

●Tracked and monitored care management services to ensure that evidence-based-medicine protocols were provided to all patients

●Performed case/disease management for Managed Medicaid patients

●Focused care coordination to reduce ER visits/hospitalizations

●Initiated HIV/AIDS disease management program

●Coordinated discharge planning and authorized medically necessary treatments

●Performed (concurrent/ancillary) reviews

●Authorized treatment care services based on medical necessity and payer coverage

●Performed medication utilization and reconciliation

●Performed retrospective claims analyses for hospital in/out-patients and physicians to verify proper coding protocols

●Supported and mentored teams in the Medical Management Division on MIlliman Care Guidelines and Interqual medical necessity criteria and clinical practice guidelines in accordance with various chronic disease states

●Attended leadership workshops and cultural competency seminars

●Participated on Six Sigma projects

EDUCATION AND TRAINING

Union County College

DIPLOMA IN NURSING

Katharine Gibbs Business School

BUSINESS CERTIFICATE

American Society Legal Nurse Consultant

CERTIFICATION

New Jersey License Life and Health Producer

Dlsi Professional Coder Program

Certified Quality Six Sigma Green Belt

NEW JERSEY HOSPITAL PRE-ADMISSION TESTING PROJECT

New Jersey License No. 26NP03325300 Expiration 5/31/2025

New York License No. 2167812 Expiration 2/28/2026

Pennsylvania License No. PN302946 Expiration 6/30/2024

Certified in Fraud, Waste, and Abuse (FWA)

References Upon Request

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