Quality, compliance, acredotstikn, customer service, leadership

Location:

Pearland, TX

Posted:

August 13, 2020

Contact this candidate

Resume:

Sharon Anne Gaddis Vollers R.N., BSN, MBA, CPHQ, CPMSM, CWC

**** *** ***** ********, ***** 77584 (mobile: 281-***-****)

*************@*****.***

Experience

September 2019-7/10/20

Chief Compliance Officer Kelsey Care Advantage

Duties: Oversee government relations, Compliance and privacy functions and activities for Medicare advantage program. internal auditing and monitoring, delegation oversight, fraud waste and abuse program. interpret policy and serve as internal resource. report monthly to board of directors on compliance and privacy programs. key accomplishments: led two mock audits, implemented delegation oversight and fraud, waste and abuse processes. TDI reporting. Plan liaison with State and Federal regulators and authorities.

Key Accomplishments: Program mock Audit; Implemented FWA and Delegation Oversight Programs. Successful Data Validation and HEDIS Audits. Maintained 5 Star Status. Revised Policy and Procedure process. Revised committee and board reporting. implemented project tracking processes.

September 2013-September 2019

Director of Quality -Memorial Hermann Health Solutions

Duties: Implementation of quality and credentialing PROGRAMS FOR 75,000+ covered lives (Fully Insured, Self Insured, Workers Comp). Lead THE ORGANIZATION through two successful accreditations and one reaccreditation. Built and developed quality and credentialing PROGRAMS, assisted on Pharmacy department creation for all product lines (Medicare, Medicaid, Self-Funded, Fully Insured, AND Employee group). Assisted with CARF reaccreditation preparations. Key Participant in establishing health plan privacy and compliance functions. Collaborated throughout the enterprise on multiple PI projects: case management, disease management, medical staff, satisfaction, employee and provider engagement, HEDIS, CAHPS, HOS, CGCAHPS, Access and Availability Standards and audits. Implemented member and provider satisfaction survey processes. Key Participant in corporate restructure of system- wide credentialing. Assumed STARS department in late 2016. Ongoing support AND PARTICIPATION IN Delegation oversight, FWA and compliance activities. Active collaboration between quality, credentialing and provider services. implemented pharmacy UM Committee.

Key Accomplishments: Implemented quality program FOR MEDICARE, Medicaid and Commercial (Fully Insured HMO and PPO, Self-Funded). Implementation of Credentialing and quality Processes compliant with state, federal and accreditation standards. Support and Internal Resource/Consultation to Medical Management, Member Services, Network and Provider Services, Compliance, Marketing/Sales and Enrollment. IMPLEMENTED MULTIPLE Quality Improvement Projects, Medical Staff Committees and Pharmacy and therapeutics Committee. Achieved Provisional Accreditation (Health Plan/Health Insurance Exchange) within six months of employment. Successful reaccreditation-Health Utilization Management. Cleared backlog of credentialing. Brought organization into compliance with regulatory and accreditation requirements. Implemented HEDIS and CAHPS processes, and focus studies. Achieved 4 STARS for Medicare Advantage Part-C . (Current projection is 4 Stars for 2019). ASSISTED Appeals and GRIEVANCES DEPARTMENT with successful TDI audits and resolution of CMS Corrective Action Plan. six sigma projects to drive quality improvement. managed MULTIPLE INTERDISCIPLINARY quality improvement projects.

2002-September 2013

Director of Quality Services-CHRISTUS Health US Family Health Plan

Served as chief clinical operations officer for health plan. Responsible for Utilization management, Case Management, Disease Management, Member Services, Patient Advocacy, Credentialing, Quality Management, Medical Staff Peer Review, Risk Management. Program integrity/Compliance, HIPAA, Records Management, ACCREDITATION, HEDIS Program, Mission and ethics, Human resources officer/Liaison for plan, USFHP employee spirituality leader.

Key Accomplishments: Turn-Around of Utilization and Case Management Departments from $6M loss to $20M Profit. 99th percentile patient and employee satisfaction for over five consecutive years. URAC Accreditation- first Time 3-Year Accreditation. Three successful re-accreditations. THREE SUCCESSFUL Implementations of DoD Contract. Development of Key COMMITTEES TO Support Strategic Directions, including Member Grievance Committee, Claims/Trends Utilization Committee, Program Integrity COMMITTEE, SPOTLIGHT subcommittee, Network Advisory Committee, Network Adequacy subcommittee, Pharmacy and Therapeutics Committee, Pharmacy Utilization Committee. Member Satisfaction >than 98th Percentile for ten consecutive YEARS, ASSOCIATE Satisfaction > 98th Percentile for ten consecutive years. Provider Satisfaction >90% for five consecutive years, Developed and Implemented 5 Star Program for Physician Recognition. UM/Case Management Re-design, mentorship to other CHRISTUS Associates. Implementation of mulitple Clinical Applications, Member Services Redesign, HEDIS data collection-achieving 95th percentile in multiple indicators. Implemented patient safety program (TEAM STEPPS), quadruple Aim program, AHRQ. Developed innovative PROGRAMS FOR oversight of clinical quality in provider offices, Developed multiple programs for member wellness, including weight management and smoking cessation. Member-National Medical Leadership Alliance, USFHP. Implemented programs to improve staff competencies including Professional Recognition program. Implemented annual nurses recognition day, including library of nursing, nurse of the year program and community nursing scholarship program for military family members. Responsible for community benefit program, providing over 10,000 hours of community benefit. Implemented Diversity and Inclusion Program at USFHP. Implemented Spirituality Program at USFHP. Responsible for Organizational Development at USFHP. implemented laughter yoga program for health plan members. Accompanied Sister Edwin and Sister FRANCES TO Washington DC for 25th Anniversary of the USFHP. Annual Caroling at the Villa De Matel.

implemented a mission, ethics and spirituality program form usfhp employees.

graduate of the christus mission and ethics institute.

Annual five Star physician recognition event gala coordinator

Annual Staff quality program presentations for Department of Defense and All-Staff. Prepared Quality outcomes presentations for congress.

CHRISTUS Health (formerly Sisters of Charity) 1998-2001

Quality Manager-Uniformed Services Family Health Plan (USFHP)

Basic job functions: Plans, implements, controls, and directs the Quality Improvement, Risk Management, Provider Credentialing programs for the USFHP (a federally contracted benefits administrator of the Tricare Prime benefit for the Department of Defense) with direct budgetary responsibility for these three programs. Participates in policy development and strategic planning. Contributes to the strategic plan through ongoing activities in relationship to managed health care environment. Identifies under-served populations within the scope of programs and plans, implements, directs, and controls same. Responsible for assisting in the advancement of USFHP’s strategic direction by designing, developing, implementing, and conducting ongoing evaluation of the Clinical Quality Management Program activities to measure and improve quality of health care provided to members. Acts as liaison with Utilization Management, and hospital Quality Improvement staff. Researches best practice and approved health care data. Prepares statistical review and analysis relating to cost, quality, and outcomes. Oversees collection, reporting, and analysis of Health Evaluation and Assessment Reporting Program. Represents Christus USFHP to wider USFHP alliance. Provides input for public policy changes (legislation) relevant to our member population. Serves as Christus USFHP liaison to the Department of Defense for Clinical Quality Improvement. Oversight responsibility of contracted entities for quality of care and services.

Major achievements: Start-up of the Clinical Quality Department of USFHP in 1998, the Credentialling department in 1999 and the Risk Management department in 2000. Created and implemented current audit tools, methods processes, policies and procedures. Developed budget and staffing plans. Responsible for implementation of various innovations as a result of quality study results. Presentations to various facilities on a variety of topics including Network Adequacy (Johns Hopkins-March 2001), Diabetic Monitoring (PacMed-Seattle, July 2001). Coordinated quality improvement initiatives using HEDIS indicators for seven USFHP’s across the nation (Sisters of Charity-New York, New York; Brighton Marine- Boston, Massachusetts; Johns Hopkins- Baltimore, Maryland; Cleveland Clinic-Cleveland, Ohio; PacMed Clinics-Seattle, Washington; Martin’s Point Health Center-Portland, Maine. Assisted USFHP alliance participants in various quality improvement projects (Domestic Violence, Behavioral Medicine Utilization Statistics-Johns Hopkins, and November 2000-March 2001).