Registered Nurse Director/Manager

Rodney D. Wilson Clinical Quality, HEDIS, Case & Risk Management, Infection

Prevention and Appeals & Grievances

********@*****.*** 281-***-**** – Katy, TX 77494

Experienced Nurse Leader within Clinical Quality, Case Management, HEDIS, Appeals & Grievances, Claims Review and Medical Insurance. Clinical experience within Cardiology/Telemetry, Hospice, Infection Control and Employee Health Program. Microsoft Certified Professional. Systems conversion and Project Management experience. Strong system background serving as Business Analyst for Medical Management. Former Medical Service Corps Officer, USAF.

Professional Experience

Cigna HealthSpring (Worldwide Health Services Organization) – Houston, TX 2019 – 2020

Quality Clinical Management Lead Analyst (Virtual, Contract)

Review potential quality of care (QOC) cases including medical record reviews, medical, dental and vision claims review, prepare summary of QOC findings, assign severity levels to cases and prepare resolution letter to customers. Prepare and send corrective action plans to individual and/or facility providers in collaboration with insurance medical directors. Interact specifically with Grievance Administration Division on identification and resolution of issues related to QOC and QOS complaints. Serve as a liaison between patient/family members and administration. Create and maintain quality management files. Trained for MedHoc conversion.

Plaza Specialty Hospital – Houston, TX 2014 – 2018

Director, Clinical Quality, Risk Management and Infection Prevention

Oversee departmental staff responsible for collecting, tracking, trending and reporting hospital key performance indicators. Investigate and resolve Quality of Care issues. Build and monitor Quality Business Plan. Prepare and present Quality Reports for Hospital Executive Management and Board of Trustees. Hospital Patient Safety and Risk Manager. Spearhead Interdisciplinary Team meetings; tracking immediate patient care issues; coordinating care issues with the case managers and attending physicians. Resolve patient appeals/grievances. Implement and ensure compliance with federal and state regulatory requirements, conduct audits and prepare hospital for Joint Commission and CMS surveys (Project Manager), oversee and manage hospital-wide infection control practices. Chart audits for present-on-admission infections. Review medical records for potential financial loss and recovery. Conduct chart audits matching Patient Care Plans to Physician Progress Notes and Operation Reports. Conduct Root Cause Analyses (RCA). Blood Utilization and Mortality Reviews.

Universal American (Medicare Advantage HMO) – Houston, TX 2008 – 2013

Quality of Care/Quality Improvement Specialist, HEDIS Extraction and Appeals & Grievance Manager:

Case Manager for assigned health insurance company patients. Conduct Quality of Care investigations and assist with directing patients to the proper specialist. Medical claims review. Collect, track, trend and report physician key performance indicators. STAR, STAR+PLUS and CAHPS reporting coupled with HEDIS Information Reporting. Oversee staff receiving, processing, tracking and resolving patient appeals and grievances. Serve as a liaison between patient/family members and administration. Prepare and present member's appeal before the Texas State Administrative Law Judge. Business Analyst for Medical Management Authorization and Delegated Entity programs. Project manager for system conversion.

HealthSouth Diagnostic Imaging Clinic – Katy, TX 2006 - 2008

Administrator: Direct financial, marketing, and daily operations of a full-service diagnostic imaging clinic generating revenue over $5.2 Million. Develop and implement Operational Business Plans. Propose and initiate medical imaging contracts; monitor contract effectiveness. Claims review. Ensure compliance with Federal and State regulatory requirements. Oversee patient insurance validation and negotiated pricing with direct-pay patients. Direct supervision over 6 technologists and 6 administrative personnel.

Select Specialty Hospital (LTAC) – Houston, TX Houston, TX 2005 - 2006

Quality Assurance/Performance Improvement Manager:

Collect, track, trend and report hospital key performance indicators. Investigate and resolve quality of care and quality of service issues. Developed reports for hospital-wide QA/PI/Infection Control, manage the Employee Health and Hospital Education programs. Investigated, researched, analyzed, trended, and reported quality measure outcomes. Serve as a liaison between patient/family members, all hospital departments and administration.

Education and Professional Certifications

Master of Public Administration

University of Oklahoma – Norman, Oklahoma

Bachelor of Science, Nursing Bachelor of Science, Business Management

Regis University – Denver, Colorado University of Maryland – College Park, Maryland

Registered Nurse, Texas License# 695853

Microsoft Certified Professional (MCDBA and MCSE) #2109731

CompTIA A+ Certified Professional# COMP10454974

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