Case Management Quality Improvement

JENNIFER ORIOL-LAMOTHE, RN, BSN, CCM, NCQA PCMH CCE

786-***-**** ady1rh@r.postjobfree.com MIAMI, FLORIDA

Passionate leader focused on Healthcare Quality Improvement and Care Management Consulting

Over 16 years of leadership experience focusing on Value-Based Care and Quality Improvement activities– HEDIS, Medicare STARS, CAHPS, HOS, NCQA PCMH, CSNP/DSNP and AAAHC Accreditation

Experienced in developing and implementing Chronic Care and Specialty Programs within several Medicare, Medicaid, MSO, and Global Health plans

Transformed over 45 Primary Care Practices into NCQA Patient Centered Medical Homes

Professional Experience

PCMH Quality Consultant Group July 2010 - Present Senior Value Based Consultant

Provide value-based consulting services on standards, policies, processes and application requirements pertinent to NCQA PCMH operations and activities as well as, other topics relating to the delivery of value-based care services and delivery

Design, revise, and evaluate training programs for practice staff on a variety of activities related to PCMH operations and activities

Perform compliance monitoring, including the oversight of audits and implementation of corrective action necessary to meet any and all requirements for government and regulatory bodies who oversee functions pertaining to PCMH

Collect and analyze qualitative and quantitative data and prepares recommendations related to clinical and operational performance

Coordinated project management, consulting and contractor engagements and relationships between senior executives

Manage practice relationships and project details to ensure project deliverables are met by the practices

Work with Practice Facilitators and Program Directors to evaluate and improve the practice transformation tools and process as needed.

Develop, review and revise a wide variety of workflows, policies and procedures to ensure operational efficiency and compliance with PCMH focused changes and requirements.

Cigna Medicare July 2021 - Present

Market Clinical Senior Advisor

Align with Network Provider Partners and Key Stakeholders to support improved healthcare quality and affordability while ensuring customer satisfaction

Execute on strategic priorities to meet organizational goals related to Customer Growth and Retention and Total Medical Cost

Partner with Business Analytics to develop Clinical Operations dashboard to identify gaps and operational compliance (CSNP/DSNP, HEDIS, Medicare STARS, HOS, CAHPS, PCMH)

Develop and maintain excellent internal relationships with key stakeholders including network

Apply fundamental knowledge of business segment strategies, distribution channels and healthcare industry trends to deliver clinical insights and consultancy in support of Network, Clinical Operations, and local market Affordability strategies

In partnership with the Market Medical Executive and Clinical Operations Team, consult regularly with provider partners on activities that drive improved performance and success in quality, affordability and experience of care

Identifying areas for improvement and recommend PCMH initiatives to improve overall quality, operations and financial outcomes

Collaborate with the DSNP/CSNP expansion Markets to ensure an effective plan is developed and enacted to drive CMS Compliance

Collaborate with Quality and Provider Operations to execute on strategies to drive key enterprise initiatives to meet clinical CMS Stars target

Cigna Global March 2020 – July 2021

Health Services Sr. Manager

Manage for the overall operations of the Cigna Global North America Case Management Department and for the development, engagement, and retention a team of a Global Nursing Case Managers based in Europe and the US

Enhance Clinical Case Management Programs to align with PCMH model of Care-CHF Program, Diabetes Empowerment Program, Transition of Care, Depression Program, Obesity Program and Maternity Program.

Coordinate, plan and manage staff activities to meet department goals inclusive of productivity, engagement rate, NPS, cost saving (>$2.5 USD million in 2020), timeframes and turnaround of cases.

Monitor case management and utilization review activities, discharge planning, Transition of Care, Coordination of care, Pre-Departure Medical assessments, Claims review, Cost Savings, Decision Support, Evacuation, Repatriation, Shipping of medications, Medical Necessity reviews and coordination of any case management needs

Monitor performance of a Case Management team to assure that case management services are delivered promptly, cost effectively, courteously and according to Policy and Procedure and Case Management standards

Maintain accurate record of case management interventions including cost/benefit analysis, savings, and data collection

Leon Medical Centers Health Plan/Cigna Medicare December 2014 – March 2020

Quality Improvement Sr. Manager

Manage the overall operations of the Quality Improvement and Risk Management Program

Responsible for the analysis of the quality of member grievance received and for the development of plans to support continuous quality improvement

Partner with providers and facilities to improve processes to reduce risk and adverse events; assisted with closing gaps to clinical operations and system processes for improving population management and reducing risk/legal issue

Collaborate with internal departments to monitor and ensure compliance with AAAHC accreditation, Agency for Health Care Administration, CMS DSNP/CSNP Model of Care and NCQA standards

Partner with cross functional teams for collaboration on Quality Improvement activities such as, CMS Star Ratings, CMS DSNP/CSNP, NCQA-HEDIS, CAHPS, HOS.

Support Stars director with development of clinical programs and interventions to improve Stars, CAHPS and HOS measures

Act as the NCQA PCMH model of care subject matter expert identification of gaps in performance, facilitate root cause analysis, and present findings and recommendations to the senior leadership.

Design and develop Quality Improvement Projects/Programs such as, CHF Program, Pneumonia/Flu Vaccine Compliance, Transition of Care, Diabetes Program, Depression Program, SDOH and Anxiety Program. Significantly increased mental health screening rates (PHQ9/GAD7) by 85% and engagement rate of 90%

Lead and serve as the lead contact for regulatory agency audits, review processes and submissions related to AHCA (100% passing rate for 5 years) and AAAHC (2019 perfect score of 100%)

Direct support with the HEDIS improvement plan, including HEDIS data collection, clinical improvement projects, strategies and initiatives to improve the scores.

Lead the management of Leon Cares member newsletters focusing on articles related to HEDIS, CMS STARS, CAHPS and HOS measures.

Health Choice Network (MSO) January 2010 – October 2014

Director of Care Management/ PCMH Project Director

Accountable for the overall performance of the Case Management operations including cost, quality and patient satisfaction and engagement

Full ownership of consulting over 30 FQHC primary practices in achieving NCQA PCMH recognition status within an accelerated 12-month time frame

Collaborate with Board of Directors to execute strategic vision for MSO and network of FQHCs

Develop and implement PCMH strategic plan and managing the successful onboarding and integration of new FQHC and providers

Provide on-site, telephonic and web-based technical assistance, training, and consultation to practices exploring or working towards the development and implementation of the PCMH model

Lead PCMH and SDOH project initiatives – Develop and track work plans, new business launch planning, KPI, Process improvement, Standardizing clinical programs and processes

Led the development and implementation of HCN Chronic Disease, Diabetes, Maternity, Lead Screening, Congested Heart Failure, Obesity and High-Cost case management programs with an engagement rate of over 85%

Coordinate care, anticipating specific needs through transitions of care and across multiple practitioners and care settings and acting to improve communications to improve quality to high risk / cost members

Education

2014-2015 Chamberlain University - BSN 2008-2010 Excelsior College RN

Licenses and Certifications

Florida Department of Health & Nursing Compact: Registered Nurse (RN)

Commission for Case Management Certification: Certified Case Manager (CCM)

National Committee of Quality Assurance (NCQA): Patient Centered Medical Home Certified Content Expert (PCMH CCE)

2021 Cigna International Markets Women Leaders Program Graduate

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