Manager Medical

Denise McMillian, MBA

Long Beach, CA

818-***-**** · *********@*****.***

Healthcare Management professional with a career path in healthcare administration and business operations. Strengths include department leadership, process improvements, program compliance, employee satisfaction, and retention. Subject matter expert in the areas of HR regulations, Credentialing, HIPAA, state and federal healthcare regulations, CMS guidelines, JCAHO and URAC standards and Compliance Regulations. Well regarded as a dynamic group motivator and performance coach with proven accomplishments in the areas of organizational and leadership assessment, staff motivation, in-service training, analytical and critical thinking skills, and developing strong relationships with external customers.

Education:

American Intercontinental University - Los Angeles, CA - Masters in Healthcare Management

University of Montevallo - Montevallo, AL - Bachelor of Science in Mass Communication

American Heritage College Orange, CA, Human Resources Management Certification

Skills and Accomplishments

Supervised Credentialing Specialists & Coordinators throughout Management career. Monitored key credentialing performance indicators, including timeliness, completeness, and accuracy of file processing. Updated physician profiles (CV, DEA license, medical license, debarment, etc).

Conducted Delegation Oversight audits with Medical Groups and reported results back to Health Plans. Monitored groups for updates and corrections until final approvals. Assisted with meetings of the Delegation Oversight Committee, including the preparation of documents for committee oversight of delegated functions.

Participated in ICE shared audit credentialing activities: annual medical group on-site audits, inter-rater reliability audits and monthly/quarterly meetings. Analyzed information, problems, situations and procedures, and defined objectives, identified patterns and formulated conclusions.

Maintained accurate reporting to Provider Enrollment database and supporting spreadsheets. Prepared documentation and materials for Health Plan Audits.

Created and maintained all Enrollment & Credentialing policies, procedures, and work instructions. Maintained provider credentialing and rosters.

Developed agenda, meeting minutes and other materials for Credentialing Committee review. Prepared, updated & submitted Policy and Procedures to the Credentialing Committee for review, recommendations, and approval.

Identified and analyzed the processes for continuous improvement opportunities that supported the overall goals of the department, including conducting audits as required of contracts, applications, turnaround time, accuracy, etc. Developed and revised as needed processes flow charts for internal and external use and distribution.

Coordinated management objectives with a focus on departmental and company-wide initiatives and team concepts. Demonstrated ability in making independent judgment and situation-specific appropriate decisions.

Guided the process of root cause analysis to identify, track and resolve adverse events encompassing the development, implementation and monitoring of government requirements.

Directed the policy and procedures initiative to guarantee compliance with government policies & agencies such as HIPAA & Medicare & Medicaid etc.

Coordinated, conducted, and documented delegation assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.

Prepared status reports from Delegated Entities. Developed corrective action plans when deficiencies were identified, and documents follow-up to completion. Ensured compliance with reporting requirements by tracking the receipt and completeness of reports. Prepared delegation oversight document evidence for state monitoring visits and NCQA accreditation surveys.

Worked with Network Management team to develop and maintain delegation agreements and assessment tools.

Managed the delivery of projects with internal and external stakeholders and agencies/vendors consistent with marketing strategy and plans to meet business objectives and goals.

Managed marketing material production by working with graphic design teams, print and fulfillment, and other vendors to ensure marketing materials are completed within budgetary constraints, required timeframes, & compliance requirements. Ensure that Chapter 3 regulatory requirements are met.

Reconciled vendor charges with requests and assigning to appropriate charge accounts. Proof draft and final copies before production.

Management & Human Resources

Hired and developed critical talent for meeting department metrics. Assessed and anticipated HR-related needs. Assisted with the onboarding process. Corporate Liaison to Imaging locations’ employees. Partnered with Talent Acquisition to provide support during the recruiting process.

Provided ongoing support for team members as needed. Ensured continuous mentoring, training and development of each team member with continuous feedback and performance monitoring. Coached & developed direct reports. Provided day-to-day performance management guidance to team members & executive management. Evaluated employees’ performance through yearly appraisals. Developed corrective action plans when compliance issues are identified, and document follow-up to completion.

Built and maintained relationship with client hospital personnel. Actively engaged client management and communicated value added services; demonstrated a strong command of the business. Coordinated and resolved issues and conflicts quickly and efficiently, balancing client and business needs. Traveled extensively to client sites in different states.

Published marketing sales guide for the Business to use during Sales & Orientation Meetings with prospective clients & new employees. Implemented & published monthly Human Resources. Credentialing Newsletter to the Business regarding system updates, Credentialing stats, surveys & audits.

Consulted with Benefits & Compensation on the bonus, merit and promotion processes, as well as supporting the Performance Appraisal process.

Conducted regular meetings with assigned business units. Interfaced with multiple Department Managers, informing them of updates, assisting with problem solving, and concerns to ensure satisfaction and compliance with Managed Care, Medicare & Medicaid.

Problem solved provider concerns and issues with discretion, confidentiality, and expediency. If needed escalated to proper unit such as Legal and Contracting etc. Conducted effective, thorough, timely and objective investigations.

Evaluated employees annually for performance through performance appraisal, coached employees regarding performance and stats, and mentored employees regarding professionalism.

Engaged in appropriate managerial practices, processes, tools and systems.

Worked closely with management and employees to improve work relationships, build morale, and increase productivity and retention. Worked in collaboration with Recruiting, Talent Acquisition, Quality Management, Operations, Human Resources, Information Systems, and other applicable departments as a key contributor in the Providers’ on-boarding process.

Regularly monitored and reviewed progress of direct reports to ensure that department goals and objectives were met and staff was held accountable for performance. Monitored, developed and implemented policies and procedures. Made recommendations for process improvement and productivity.

Technical:

MS Office Suite, VISTAR, CACTUS, Intellicred, Morrisey MSOW, EZ-CAP, PECOS, Adobe, ADP, Sharepoint, ACCESS, One App Pro, Lotus, SAP, Ontrac, Itrac, Access, Virtual Credentialer, Salesforce, etc.

Work Experience:

2018 - 2019 Medicare Ops Project Management Specialist, Blue Shield (Latitude 36) Monterey Park, CA

2017 – 2018 Credentialing Supervisor/Specialist, UCLA Faculty Practice Group (Robert Half) LA, CA

2016 – 2016 Credentialing Supervisor, Prospect Medical Group, Orange CA

2015 – 2016 Contracting & Credentialing Coordinator, Windstone Behavioral Health, CM, CA

2014 – 2015 Credentialing Supervisor, March Vision Care, Los Angeles, CA

2013 – 2014 Human Resources Credentialing Manager, Alliance Imaging, Newport Beach, CA

2013 – 2013 Credentialing Manager, Accountable HealthCare IPA, Signal Hill, CA

2011 – 2013 Manager of Delegation Oversight, Arcadian Health Plan / HUMANA, San Dimas, CA

2010 – 2011 Special Needs Program Case Management Lead Health Net Woodland Hills, CA

2009 – 2010 Credentialing Coordinator, Synermed, Monterey Park, CA

2007 – 2013 Assistant Floor Manager, Catherine’s Burbank, CA

2005 – 2007 Utilization Management Case Senior Associate Supervisor, CIGNA, Glendale, CA

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